IMCI
INTEGRATED MANAGEMENT
OF CHILDHOOD ILLNESS
DISTANCE LEARNING COURSE
Module 8
HIV/AIDS
WHO Library Cataloguing-in-Publication Data:
Integrated Management of Childhood Illness: distance learning course.
15 booklets
Contents: – Introduction, self-study modules – Module 1: general danger signs for the
sick child – Module 2: The sick young infant – Module 3: Cough or difficult breathing
– Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia
– Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well child –
Facilitator guide – Pediatric HIV: supplementary facilitator guide – Implementation:
introduction and roll out – Logbook – Chart book
1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control.
4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education, Distance.
7.Teaching Material. I.World Health Organization.
ISBN 978 92 4 150682 3 (NLM classification: WS 200)
© World Health Organization 2014
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Printed in Switzerland
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
n CONTENTS
Acknowledgements4
8.1
Module overview
5
8.2
Basic information about HIV
9
8.3
HIV testing
16
8.4
Assess & classify a sick child
24
8.5
Assess & classify a sick young infant
31
8.6
Prophylaxis and other preventative measures
36
8.7
Counsel HIV-infected mothers about infant feeding
47
8.8
Antiretroviral treatment
63
8.9
Providing follow-up care
91
8.10
Review questions
110
8.11
Answer key
111
ANNEXES
Annex 1 Clinical staging
121
Annex 2 Treatment dosing tables
123
3
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
Acknowledgements
The WHO Department of Maternal, Newborn, Child and Adolescent Health initiated
the development of these distance learning materials on the Integrated Management
of Childhood illness (IMCI), in an effort to increase access to essential health services
and meet demands of countries for materials to train primary health workers in
IMCI at scale. These materials are intended to serve as an additional tool to increase
coverage of trained health workers in countries to support the provision of basic
health services for children. The technical content of the modules are based on new
WHO guidelines in the areas of pneumonia, diarrhoea, febrile conditions, HIV/
AIDS, malnutrition, newborn sections, infant feeding, immunizations, as well as
care for development.
Lulu Muhe of the WHO Department of Maternal, Newborn, Child and Adolescent
Health (MCA) led the development of the materials with contributions to the content
from WHO staff: Rajiv Bahl, Wilson Were, Samira Aboubaker, Mike Zangenberg,
José Martines, Olivier Fontaine, Shamim Qazi, Nigel Rollins, Cathy Wolfheim,
Bernadette Daelmans, Elizabeth Mason, Sandy Gove, from WHO/Geneva as well
as Teshome Desta, Sirak Hailu, Iriya Nemes and Theopista John from the African
Region of WHO.
A particular debt of gratitude is owed to the principal developer, Ms Megan Towle.
Megan helped in the design and content of the materials based on the field-test
experiences of the materials in South Africa. A special word of thanks is also due to
Gerry Boon, Elizabeth Masetti and Lesley Bamford from South Africa and Mariam
Bakari, Mkasha Hija, Georgina Msemo, Mary Azayo, Winnie Ndembeka and Felix
Bundala, Edward Kija, Janeth Casian, Raymond Urassa from the United Republic
of Tanzania
WHO is grateful for the contribution of all external experts to develop the distance
learning approaches for IMCI including professor Kevin Forsyth, Professor David
Woods, Prof S. Neirmeyer. WHO is also grateful to Lesley-Anne Long of the Open
University (UK), Aisha Yousafzai who reviewed the care for development section
of the well child care module, Amha Mekasha from Addis Ababa University and
Eva Kudlova, who have contributed to different sections of the distance learning
modules.
We acknowledge the help from Ms Sue Hobbs in the design of the materials.
Financial and other support to finish this work was obtained from both the MCA
and HIV departments of WHO.
4
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
8.1
MODULE OVERVIEW
This module will teach you how IMCI can assist in providing critical HIV/AIDS care,
treatment, support, and prevention.
Worldwide, 3.4 million children were living with HIV in 2011
First, this module will explain basic information about HIV and how children are
infected. This information will help you better manage children with suspected or
confirmed infection. Next, you will learn how to assess and classify HIV in young
infants and children. You will learn how to provide follow-up care for exposed
and infected children. The module will also explain how to counsel HIV-positive
mothers about safe feeding, and methods for further preventing illness in exposed
and infected children. Lastly, you will learn how to provide antiretroviral treatment
and provide follow-up.
MODULE OBJECTIVES
After you study this module, you will know how to:
✔✔ Explain in basic terms how HIV affects the immune system
✔✔ Explain how children are infected with HIV
✔✔ Assess and classify a child for HIV
✔✔ Assess and classify a young infant for HIV
✔✔ Provide follow-up care to HIV exposed and infected children that are not on ART
✔✔ Counsel an HIV-infected mother about safe infant feeding, and preventing
common illnesses in infants and young children exposed to, or infected with,
HIV through cotrimoxazole prophylaxis, ARV prophylaxis, immunization, and
Vitamin A supplementation
✔✔ Explain and provide the recommended ARV regimens for children
✔✔ Explain the criteria for initiating ART in children at first-level facilities
✔✔ Describe the WHO paediatric clinical staging process
✔✔ Identify the possible side effects of ARV drugs and explain the management of
possible side effects
✔✔ Counsel the caregiver on giving ART and adherence
✔✔ Explain the principles of good follow-up care
✔✔ Provide chronic care for children with confirmed HIV infection and on ART
5
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
MODULE ORGANIZATION
This module is divided into multiple sections:
1. BASIC INFORMATION ABOUT HIV
2. HIV TESTING
3. ASSESSING & CLASSIFYING A CHILD FOR HIV
4. ASSESSING & CLASSIFYING A YOUNG INFANT FOR HIV
5. PROPHYLAXIS AND PREVENTIVE MEASURES
6. COUNSELLING THE HIV-POSITIVE MOTHER ABOUT INFANT FEEDING
7. ANTIRETROVIRAL THERAPY (ART)
8. PROVIDING FOLLOW-UP CARE
WHY IS THE IMCI STRATEGY USED WITH HIV?
Children with suspected or confirmed HIV infection have special needs. Therefore
they need to be cared for differently from children who are not infected.
As you have learned, the IMCI strategy is designed to help health workers identify
common health problems in children. It also helps identify underlying issues, like
malnutrition and HIV.
WHERE DOES HIV FIT IN THE IMCI PROCESS?
You have learned that for every sick child or young infant, you check for signs of
serious illness, assess and classify main symptoms, and check for malnutrition and
feeding problems. Next, you will ASSESS and CLASSIFY for HIV using the same
process.
CHECK for general danger signs or signs of serious illness ASSESS & CLASSIFY main symptoms CHECK for malnutrition of feeding problems CHECK for HIV infection
CHECK immunizations and for other problems
6
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
WHAT IMCI TOOLS WILL YOU USE?
For this module, you will continue to use work aids provided earlier in the course:
1. IMCI Chart Booklet for HIV settings
2. IMCI recording forms for sick young infant and sick child
You will also have additional work aids that are specific to HIV/AIDS care:
3. ART initiation form for the sick child (2 months up to 5 years)
4. ART follow-up form for the sick child (2 months up to 5 years)
Open your chart booklets now to review each of these tools. Identify the recording
forms you will use for each set of charts.
BEFORE YOU BEGIN
What do you know now about managing HIV care?
Before you begin studying this module, quickly practice your knowledge with these
multiple-choice questions.
Circle the best answer for each question.
1. A child is under 16 months old. What HIV test should be used for this child,
and why?
a. Serological tests, because it can detect if virus antibodies are present
b. Virological (PCR) tests, because it can actually detect the virus
c. Serological tests now, but after the child is 18 months, confirm with a PCR
2. What follow-up treatments are critical for HIV-exposed and infected infants
and children?
a. Cotrimoxazole prophylaxis
b.Paracetamol
c.Amoxicillin
3. What is the overall risk of a mother transmitting HIV to her child during
pregnancy, labour and delivery, and breastfeeding if no prophylaxis is used
during prevention of mother-to-child transmission?
a.70%
b.10%
c.35%
4. A 2-month breastfeeding baby has a positive virological (PCR) test. Is the child
HIV infected?
a. Yes, HIV-infected
b. No, HIV negative
c. Possibly, he is HIV exposed
5. When is an HIV-positive child or infant eligible for ART?
a. If a child has stage 2 HIV infection
b. Any child under five with confirmed HIV infection
c. Children over 5 years old with a count less than 350 cells per mm3
7
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
6. If a mother is HIV-positive, but the child is not confirmed with HIV infection,
what is the recommended feeding practice?
a. Exclusive breastfeeding as long as the child wants
b. Breastfeeding and also formula, in order to provide additional nutrition
c. Exclusive breastfeeding until 12 months
After you finish the module, you will answer the same questions. This will
demonstrate to you what you have learned during the course of the module!
8
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
8.2
BASIC INFORMATION ABOUT HIV
What are the learning objectives for this section?
After you study this section, you will know how to:
•• Explain in basic terms how HIV affects the immune system
•• Explain how HIV is transmitted to infants and children
WHAT IS THE IMMUNE SYSTEM?
Every healthy person has a strong system to defend the body against diseases. This
defence system is called the immune system.
White blood cells are an important part of this defence system. They protect the
body against all kinds of diseases. They can be thought of as the “soldiers” of the body.
HOW DO WHITE BLOOD CELLS ACT AS “SOLDIERS”?
Lymphocytes are one type of white blood cell in the body.
Some of these lymphocytes have a marker on their surface
called CD4. Therefore they are called CD4 lymphocytes. These
CD4 lymphocytes are responsible for warning your immune
system that there are germs trying to invade the body.
HIV (Human Immunodeficiency Virus) is a virus that
infects and takes over cells of the immune system. Although
HIV infects a variety of cells, its main target is the CD4
lymphocyte.
CD4 lymphocytes warn
your immune system that
there are germs trying to
invade the body.
HIV infects cells of the
immune system. Its
main target is the CD4
lymphocyte.
HOW DO VIRUSES INFECT THESE CELLS?
The human body is made of millions of different cells. Each body cell is able to make
new cell parts, in order to stay alive and to reproduce.
Viruses take advantage of this ability. They hide their own material in the centre
of the cell, called the nucleus. When the cell tries to make its own new parts, it
also makes new copies of the virus. When the HIV virus infects CD4 lymphocytes,
HIV uses the CD4 cell to make new copies of the HIV virus. These copies go on to
infect other cells.
WHAT DOES HIV DO TO CD4 LYMPHOCYTES?
CD4 cells infected with HIV are not able to work very well. They die early. When
the immune system loses these CD4 cells, the immune system becomes weaker.
This makes children (and adults) much more likely to develop illness from the
types of germs that would not normally cause them to be ill, or to be more sick
with common germs.
These infections are called opportunistic infections. They take the opportunity
of the body’s defence system being weak to flourish.
9
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
Figure 1 summarizes what happens to HIV after it enters a human cell.
Figure 1. HIV entering the cell and making new copies
HIV attacks many CD4 cells. The infected CD4 cell will first produce many new copies of the virus, and
then die.
The new copies of HIV will then attack other CD4 cells, which will also produce new copies of HIV and
then die.
This goes on and on – more CD4 cells are destroyed, and more copies of HIV are made.
10
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
HOW IS HIV MONITORED ONCE IT INFECTS THE BODY?
When a person gets infected with the HIV, the virus will start to
attack his/her immune system. Since HIV mostly attacks CD4
cells, there is a measurement of the number of CD4 cells in an HIVinfected person’s blood. This is a good way of checking how well
their defence system is still working. This is called a CD4 count.
CD4 counts tell
you how healthy a
person’s immune
system is.
HOW DOES HIV AFFECT ADULTS?
During the first years following infection, an adult’s immune system can still
function quite well, even though the HIV virus is slowly damaging the immune
system. The infected adult will have no symptoms, or only minor symptoms such
as swollen lymph nodes or mild skin diseases. At this stage, most adults do not
even know that are infected with HIV.
Usually after several years, the adult’s immune system gets more and more damaged
and weaker. The person becomes vulnerable to germs and diseases that they normally
fight off. These infections are called ‘opportunistic infections’ because they take
advantage of the weak immune system to cause disease.
In adults it usually takes around 7–10 years after the initial infection with HIV before
the person becomes ill and develops serious sickness from HIV. HIV is considered
to have progressed to AIDS when these sicknesses occur and a CD4 count
reaches below a certain number.
HOW DOES HIV AFFECT CHILDREN DIFFERENTLY THAN ADULTS?
HIV infection progresses much more rapidly in children as compared to adults. The
course of HIV infection is different in children than in adults because children’s
immune systems are not yet well developed.
HIV seems to damage the immune system more easily in children. This is
especially true if the child is infected with HIV while in the mother’s womb, or at
the time of delivery.
Children are also more susceptible to common infections or unusual
opportunistic infections. In the same way as adults, when the child’s immune
system gets damaged it becomes weak. Children can get sick from germs that do
not usually cause serious disease. For example, a child may normally have candida
bacteria living in the mouth. However, when the immune system
is damaged, the candida causes mouth ulcers or soreness. This is
HIV can usually
called oral thrush.
As the damage to the immune system gets worse, children
become highly vulnerable to life-threatening illnesses such as
PCP pneumonia, unusual cancers (lymphoma), recurrent bacterial
infections, and HIV brain damage (encephalopathy). These are
considered AIDS-defining diseases because they are often seen once
a child’s immune system is not performing well due to HIV infection.
As the HIV disease progresses, a child’s CD4 percent or total
count gets less. Figure 2 illustrates how HIV attacks our health.
11
weaken or destroy
the immune system
in children much
more quickly.
Children progress
from HIV to AIDS
more rapidly.
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
Figure 2. How HIV attacks the body
1. The CD4 cell is a kind of white blood cell. The CD4
is the friend of our body.
body
2. Problems like cough try to attack our body, but the
CD4 fights them to defend the body, his friend.
CD4
3. Problems like diarrhoea try to attack our body, but
CD4 fights them to defend the body.
4. Now, HIV enters and starts to attack the CD4.
5. The CD4 notices he cannot defend himself against
HIV!
6. Soon, CD4 loses his force against HIV.
7. CD4 loses the fight. The body remains without
defence.
8. Now the body is alone without defence. All
kinds of problems, like cough & diarrhoea, take
advantage and start to attack the body.
9. In the end, the body is so weak that all the diseases can attack without difficulty.
12
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
HOW ARE CHILDREN INFECTED WITH HIV?
Mother-to-child transmission of HIV (MTCT) is the main way that young
children are infected with HIV. This is also called vertical transmission.
Other ways in which children can get HIV are sexual abuse, unsafe injections, or
blood transfusion with blood products that are infected with HIV.
HOW DOES MOTHER-TO-CHILD TRANSMISSION OF HIV OCCUR?
Mother-to-child transmission (MTCT) is when an HIV infected woman passes the
virus to her baby. This can happen without the mother’s knowledge is she does
not know her status. HIV can be transmitted from mother to child during several
methods, and times:
1. Pregnancy (in utero)
2. Labour and delivery (peri or intrapartum)
3. Breastfeeding (postpartum)
Not all HIV infected women will automatically transmit the virus to their
child.
WHAT IS THE RISK OF MOTHER-TO-CHILD TRANSMISSION?
Look at the diagram below. This will be an example. Consider 20 babies born to 20
HIV-infected women. If nothing is done to prevent HIV transmission in these 20
babies, then approximately 7 of the 20 women will transmit HIV to their infants
during pregnancy, labour, delivery, or breastfeeding. This means that the overall
risk of MTCT is about 35%.
This is visualized in the picture below, where 7 of 20 of babies are shaded. Of these
7 babies, it is estimated that about 4 of them (or 20% of the total infection risk)
would be infected during pregnancy, labour, or delivery. The remaining 3 babies (or
about 15% of the total infection risk) would be infected during breastfeeding. This
risk is decreased if the mother or child receives ART prophylaxis.
If 20 women deliver babies without any intervenKon 4 (20%)
3 (15%)
infected
infected
to reduce mother-­‐to-­‐child HIV transmission: during
during
pregnancy,
breast-
or on a
feeding
How labout
m
any verage will be infected? 7 out of 20 delivery
PREGNANCY & DELIVERY 4 out of 20 BREASTFEEDING 3 out of 20 13
NOT INFECTED 13 out of 20 IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
Why does transmission risk change during pregnancy, delivery, and
breastfeeding?
The risk of transmission during pregnancy is low, as the placenta
protects the developing baby. During labour and delivery the risk is
increased through sucking, absorbing, or aspirating blood or cervical fluid.
Exclusive
breastfeeding
reduces the
risk of HIV
transmission.
Mixed feeding, compared to exclusive feeding, may increase
the risk of HIV transmission. Studies have shown that exclusive
breastfeeding carries a smaller risk of HIV transmission when compared
with mixed feeding. This is due to potential damage to the lining of the infant’s
gut by food particles or the introduction of an allergen or bacteria that causes
inflammation. This can lead to easier access of the HIV virus from the mother’s
breast milk into the infant’s blood.
IMPORTANT NOTE ABOUT MOTHER-TO-CHILD TRANSMISSION
The term mother-to-child transmission is used in this document because the source of the child’s HIV
infection is the mother. Use of the term mother-to-child transmission does not imply blame, whether or
not a woman is aware of her own infection status.
A woman can acquire HIV through unprotected sex with an infected partner, or by receiving contaminated
blood through non-sterile instruments or medical procedures.
WHAT DOES IT MEAN TO BE ‘HIV EXPOSED’?
For the purposes of this course, HIV-exposed infants are born to women who are
known to be HIV-infected. HIV-exposed infants or children cannot be considered
HIV-positive or HIV-negative until their status is confirmed with an appropriate
HIV test.
WHAT HAPPENS IF HIV-INFECTED CHILDREN ARE UNTREATED?
If untreated, three-quarters (75%) of children who are infected through MTCT will
develop problems from HIV and will die before the age of five.
For children who are infected through mother-to-child transmission and who do
not receive any antiretroviral treatment or cotrimoxazole prophylactic therapy:
about one-third will die by one year of age, and half will die by two years of age.
Many of these infant deaths occur at home before presentation to health care
facilities. Children with HIV infection can develop severe illness very quickly.
They may not present with the classic picture of chronic wasting and decline that is
commonly seen in adults with HIV or AIDS. HIV/AIDS is rapidly fatal in children
– this is why early HIV diagnosis essential.
14
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
HOW CAN DEATHS FROM HIV BE PREVENTED IN CHILDREN?
Important interventions to reduce the risk of children dying from HIV includes:
1. Early diagnosis of HIV
2. Initiating Antiretroviral Therapy (ART)
3. Initiating other prophylaxis and treatments
Infants are most at risk of developing serious complications and dying from HIV
infection – therefore it is most important that these children are identified, and
placed on treatment. You will now read more in the following sections about
each of these points for preventing deaths: early diagnosis through HIV
testing, prophylaxis, treatments, and ART.
SELF-ASSESSMENT EXERCISE A – HIV TERMS
Define the following terms in a way that you would explain to a caretaker.
1. Immune system:
2.CD4:
3. Opportunistic infection:
15
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
8.3
HIV TESTING
What are the learning objectives for this section?
After you study this section, you will know how to:
•• Explain the types of HIV tests available in your country
•• Interpret the tests based on a child’s age, breastfeeding status, and mother’s
status
16
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
n OPENING CASE STUDY – PETER
Peter is 6 months old. His mother, Lungile, brought him to your clinic because he had cough for the last
3 days. Peter has no general danger signs. He breathes 54 per minute but he has no chest indrawing and
no stridor or wheeze. He has no diarrhoea, fever, or ear problems. His weight is 7.2 kg. His temperature is
37.5 degrees. Lungile is worried. She was recently told she has HIV. She is receiving care at another clinic.
How will you assess and classify Peter?
First, you know that you will use the sick child charts because Peter is between 2 months and 5 years of
age. You record Peter’s important information at the top of the recording form. You assess his cough: he has
fast breathing but no other signs. You classify as PNEUMONIA. You do not classify for diarrhoea, fever, or ear
problems. He is not low weight for age. Lungile tells you she breastfed Peter until he was 4 months old.
How will you record this information on Peter’s recording form?
MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS
Name:
Ask: What are the child's problems?
ASSESS (Circle all signs present)
CHECK FOR GENERAL DANGER SIGNS
NOT ABLE TO DRINK OR BREASTFEED
VOMITS EVERYTHING
CONVULSIONS
Age:
Weight (kg):
Initial Visit?
LETHARGIC OR UNCONSCIOUS
CONVULSING NOW
Temperature (°C):
Follow-up Visit?
CLASSIFY
General danger sign
present?
Yes ___ No ___
Remember to use
Danger sign when
selecting
classifications
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?
Yes __ No __
DOES THE CHILD HAVE DIARRHOEA?
Yes __ No __
For how long? ___ Days
For how long? ___ Days
Is there blood in the stool?
Count the breaths in one minute
___ breaths per minute. Fast breathing?
Look for chest indrawing
Look and listen for stridor
Look and listen for wheezing
Look at the childs general condition. Is the child:
Lethargic or unconscious?
Restless and irritable?
Look for sunken eyes.
Offer the child fluid. Is the child:
Not able to drink or drinking poorly?
Drinking eagerly, thirsty?
Pinch the skin of the abdomen. Does it go back:
Very slowsly (longer then 2 seconds)?
Slowly?
DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5°C or above)
Decide malaria risk: High ___ Low ___ No___
For how long? ___ Days
If more than 7 days, has fever been present every
day?
Has child had measels within the last 3 months?
Do malaria test if NO general danger sign
High risk: all fever cases
Low risk: if NO obvious cause of fever
Test POSITIVE? P. falciparum P. vivaxNEGATIVE?
Look or feel for stiff neck
Look for runny nose
Look for signs of MEASLES:
Generalized rash and
One of these: cough, runny nose, or red eyes
Look for any other cause of fever.
If the child has measles now or within the
last 3 months:
Look for mouth ulcers.
If yes, are they deep and extensive?
Look for pus draining from the eye.
Look for clouding of the cornea.
DOES THE CHILD HAVE AN EAR PROBLEM?
Is there ear pain?
Is there ear discharge?
If Yes, for how long? ___ Days
THEN CHECK FOR ACUTE MALNUTRITION
AND ANAEMIA
Look for pus draining from the ear
Feel for tender swelling behind the ear
Yes __ No __
Yes __ No __
Look for oedema of both feet.
Determine WFH/L _____ Z score.
For children 6 months or older measure MUAC ____ mm.
Look for palmar pallor.
Severe palmar pallor? Some palmar pallor?
Is there any medical complication?
General danger sign?
Any severe classification?
Pneumonia with chest indrawing?
For a child 6 months or older offer RUTF to eat. Is the child:
Not able to finish or able to finish?
For a child less than 6 months is there a breastfeeding problem?
If child has MUAC less than 115 mm or
WFH/L less than -3 Z scores or oedema of
Lungile
told you she is HIV-infected. Now you will learn about HIV tests used for sick children and
bothhas
feet:
infants in your country.
CHECK FOR HIV INFECTION
Note mother's and/or child's HIV status
Mother's HIV test:
NEGATIVE POSITIVE
NOT DONE/KNOWN
Child's virological test: NEGATIVE POSITIVE
NOT DONE
Child's serological test: NEGATIVE POSITIVE
NOT DONE
If mother is HIV-positive and NO positive virological test in child:
Is the child breastfeeding now?
Was the child breastfeeding at the time of test or 6 weeks before it?
If breastfeeding: Is the mother and child on ARV prophylaxis?
17
CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today)
Return for next
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
WHY DOES HIV TESTING IMPORTANT FOR IMCI?
In order to assess and classify a child for HIV, you need to know if he or she has
already had an HIV test.
Open your chart booklet and review the ASSESS and CLASSIFY table for
HIV. You will see there are two sets of charts. These are based on whether or not
the child has been tested for HIV. You will now learn about HIV tests, and then you
will continue on to assessing and classifying.
WHEN IS IT NECESSARY TO TEST A CHILD FOR HIV?
You will encourage HIV testing for:
■■ All children born to an HIV-infected mother
■■ All children that do not have a known test result, and you do not know the
mother’s status
■■ In a high HIV setting, every child who is sick should be tested for HIV
WHAT ARE HIV TESTS?
Different tests are available to diagnose HIV infection. It is first important to
understand the different tests – some detect antibodies, and others detect the virus
itself. The results from these two tests are understood differently. Review these two
test types in the table:
SEROLOGICAL TESTS
including rapid tests
What does the test detect?
How can you interpret the test?
These tests detect antibodies
made by immune cells in response
to HIV.
HIV antibodies pass from the mother to the child. Most
antibodies have gone by 12 months of age, but in some
instances they do not disappear until the child is 18 months
of age.
They do not detect the HIV virus
itself.
VIROLOGICAL TESTS
including DNA or RNA
PCR
These tests directly detect the
presence of the HIV virus or
products of the virus in the blood.
This means that a positive serological test in children under
the age of 18 months is not a reliable way to check for
infection of the child.
Positive virological (PCR) tests reliably detect HIV infection
at any age, even before the child is 18 months old.
If the tests are negative and the child has been
breastfeeding, this does not rule out infection. The baby
may have just become infected. Tests should be done six
weeks or more after breastfeeding has completely stopped –
only then do the tests reliably rule out infection.
Now you will read more about these tests and their relevance for different age groups:
children under 18 months, and 18 months or older.
18
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
WHAT TEST SHOULD BE USED IF THE CHILD IS 18 MONTHS OR OLDER?
You will use a serological test to determine the HIV status of a child 18 months
or older. If the serological test is positive it confirms the child’s status as HIVinfected.
WHAT TEST SHOULD BE USED IF THE CHILD IS UNDER
18 MONTHS OLD?
A virological test (PCR) is the only reliable method to determine the child’s HIV
status below 18 months of age. It detects the actual virus in the child’s blood.
Remember that serological tests do not determine HIV status in this age
group. This is because the test may detect antibodies that might have passed from
the mother through the placenta. Therefore a positive serological test may only
tell you that the child has been exposed to HIV, rather than that the child is HIVinfected.
THERE ARE TWO SCENARIOS FOR CHILDREN UNDER 18 MONTHS:
This depends on the availability of PCR in your country:
1. IF PCR or other virological TEST IS AVAILABLE, TEST FROM 4–6 WEEKS OF
AGE
+ A POSITIVE result means that the child is infected, as it detects the actual
presence of HIV in the child
–A NEGATIVE result means that child is not infected, but could become
infected if they are still breastfeeding
2. IF PCR or other virological TEST IS NOT AVAILABLE, USE A SEROLOGICAL
TEST
+A POSITIVE result is consistent with the fact that the child has been exposed
to HIV, but does not tell us if the child is definitely infected. All HIV-exposed
infants should be tested using PCR or other virological test.
–A NEGATIVE result usually means the child is not infected. A negative test
is also useful because it usually excludes HIV infection from the mother, as
long as the child has not breastfed for more than 6 weeks.
HOW WILL YOU INTERPRET A SEROLOGICAL TEST IN A CHILD
UNDER 18 MONTHS?
As you have read, the breast milk of an HIV-positive mother can transmit HIV. You
see in the chart that this affects how you will interpret test results.
Is child breastfeeding?
POSITIVE (+) test
NEGATIVE (-) test
NOT BREASTFEEDING, and
has not in last 6 weeks
HIV exposed and/or HIV infected –
Manage as if they could be infected. Repeat
test at 18 months.
HIV negative
Child is not HIV infected
BREASTFEEDING
HIV exposed and/or HIV infected –
Manage as if they could be infected. Repeat
test at 18 months or once breastfeeding has
been discontinued for more than 6 weeks.
Child can still be infected by breastfeeding.
Repeat test once breastfeeding has been
discontinued for more than 6 weeks.
19
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
REVIEW THE EARLY INFANT DIAGNOSIS
ALGORITHM BELOW:
charts
help you
make decisions
about the
testing course of action for
Review This
the flow
early infant diagnosis algorithm below: under
months.
It provides
more cspecifics
addition
the under This flow cchildren
harts help you 18
make decisions about tsome
he testing ourse of inaction for ctohildren information
you
readm
on
thespecifics previousin page.
18 months. It provides some ore addition to the information you read on the previous page. HIV-­‐exposed Infant or child <18 months Conduct diagnostic v iral testa Viral test available Positive Viral test not available Negative Infant/child is likely infected Never breastfed Ever breastfed or currently breastfeeding <24 months: immediately start ARTb Infant/child is uninfected Infant /child remains at risk for acquiring HIV infection until complete cessation of breastfeedingc And repeat viral test to confirm infection Infant/child develops signs or symptoms suggestive of HIV Infant remains well and reaches 9 months of age Conduct HIV antibody test at approximately 9 months of age Viral test not available Viral test available Positive Positive Negative Viral test not available assume infected if sick assume uninfected if well well Infant/child is infected sick Negative Regular and periodic clinical monitoring HIV unlikely unless still breastfeedingc Start ARTb And repeat viral test to confirm infection Repeat antibody test at 18 months of age and/or 6 weeks after cessation of breastfeeding For newborn, test first at or around birth or at the first postnatal visit (usually 4–6 weeks).See also Table 5.1 in text on infant
diagnosis.
b
Start ART, if indicated, without delay. At the same time, retest to confirm infection.
c
The risk of HIV transmission remains as long as breastfeeding continues.
a
20
dIMCI SELF-­‐STUDY MODULES | World Health Organization 16 IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
WHAT MOTHERS NEED TO BE COUNSELLED FOR THEIR CHILD’S
HIV TEST?
Many mothers, and even health workers, are reluctant to discuss HIV.
However, HIV is present in the community and the problem will not be solved as
long as there is secrecy surrounding the topic. The mother of a child classified as
HIV EXPOSED will need to be counselled about an HIV test for the child. These
children all require HIV tests and re-classification based on these tests.
WHAT INFORMATION SHOULD BE PROVIDED TO THE MOTHER?
When you have identified a young infant or child who is in need of HIV testing you
should provide the mother with information:
•• Explain why it is important to test the child (e.g. status is unknown).
•• Help the mother to understand that the reason for HIV testing is so that the
child can receive treatment that will improve his quality of life. He should have
antibiotics to prevent infections, vitamin supplementation, regular growth
monitoring, treatment of any illnesses, and antiretroviral therapy if needed. If
the child is less than about 2 years, counsel on infant feeding.
HOW CAN YOU HELP ADDRESS A CAREGIVER’S CONCERNS?
Once you have explained, allow the mother to ask questions and address her
concerns. If she agrees to the test, arrange it in the normal way at your clinic.
Since the most common route of HIV infection for a child is by mother-to-child
transmission, you may need to discuss testing her and her partner as well perhaps
even before testing the child.
Mother-to-child transmission presents a number of barriers to testing of
the child. HIV may provoke feelings of guilt on the part of the mother, as well as
fears of rejection by and of the child and of revealing their own HIV status and how
they were infected. All health workers must be equipped with the knowledge and
ability to discuss HIV, ask questions and give appropriate counselling.
WHAT SHOULD A HEALTH WORKER DO IF A MOTHER REFUSES
TESTING?
If a mother does not agree to test the child, the health worker should listen to
and address her concerns and reasons against testing. The health worker may be
considered an advocate for the child and negotiate with the parent or carer in the
child’s best interest. Reassurances should be made regarding treatment, care, support
and/or preventive interventions that the child may benefit from once diagnosed. It
may help for the parent/carer to express their concerns without the child’s presence.
WHAT STEPS SHOULD BE TAKEN AFTER TESTING?
After testing, make an appointment for a review of the results and post-test
counselling. If a serological test has been performed, do the post-test counselling
immediately if this is agreeable to the mother. Maintain privacy and confidentiality
so that the mother can discuss her concerns freely.
21
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
After you explain information, allow the mother to ask questions.
Address her concerns.
SELF-ASSESSMENT EXERCISE B – HIV TESTING
Complete the following questions to practice what you have learned about HIV
tests.
1. What is the difference between an HIV virological (PCR) test and an HIV
serological test?
2. What test would you use to confirm HIV infection in a child under the age of 18
months?
3. A 20 month old baby has a positive virological (PCR) test. Is the child HIV
infected?
4. A 2 month old breastfeeding baby has a positive HIV serological test. Is the child
HIV infected?
5. A 2 month old baby has a positive virological (PCR) test. Is the child HIV infected?
6. A 21 month child has a negative serological test. Child has not breastfed since
he was 6 months old. Is the child HIV infected?
7. An 18 month old breastfeeding child has a positive HIV serological test. Is the
child HIV infected?
8. A 9 month old breastfeeding baby has a negative virological (PCR) test. Is the
child HIV infected?
9. A 9 month old baby has a negative virological (PCR) test. The baby last breastfed
3 months ago. Is the child confirmed HIV negative?
10.A 16 month old child has a negative serological test. The child is not breastfeeding.
Is the child confirmed HIV negative?
22
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
SUMMARY: WHAT DID YOU LEARN IN THIS SECTION?
Review the main points from this section. Reading this summary, and completing
the self-assessment exercises in the module, are important for learning.
1. HIV testing is essential for assessing and classifying a child for HIV
You will assess a child based on his HIV tests and clinical signs.
2. A positive serological HIV test cannot confirm HIV infection for children
below 18 months. This is because the test shows the presence of antibodies
– and children under 18 months can still have antibodies from their mothers.
However, a negative test is useful because it usually excludes HIV infection from
the mother, so long as the child has not been breastfed for more than 6 weeks.
3. A positive serological HIV test cannot confirm HIV infection for children
below 18 months. This is because the test shows the presence of antibodies,
and children under 18 months may have antibodies present from their mothers.
4. Breastfeeding matters
A child can be infected with HIV through breast milk. An HIV test can only be
confirmed once a child has stopped breastfeeding for at least 6 weeks.
23
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
8.4
ASSESS & CLASSIFY A SICK CHILD
What are the learning objectives for this section?
After you study this section, you will know how to:
•• Assess a sick child for HIV by using their test results or clinical signs of HIV
•• Classify a sick child for HIV
IN SUMMARY, HOW DO YOU KNOW WHEN A CHILD IS
HIV INFECTED?
In the last section you learned about HIV testing, and how to interpret results by
age group and by breastfeeding status. These test results will determine how you
assess and classify the child or sick young infant.
SUMMARY: how do you know when a child is HIV infected?
n POSITIVE VIROLOGICAL (PCR) TEST at any age with a confirmatory test
n POSITIVE SEROLOGICAL TEST at 18 months or older with a confirmatory test
Remember that test results are not confirmed unless child has not been breastfeeding for at least 6 weeks. Children
can still be infected by breastfeeding.
HOW WILL YOU USE TEST RESULTS TO ASSESS?
To ASSESS a child for HIV, you will use: (a) test results, if available, and (b) clinical
signs. The first step in assessing is to determine whether or not there are test results
available for the child or mother. This will help determine your steps for ASSESSING.
For ALL sick children – ask the caretaker about the child’s problems, check for
general danger signs, assess for cough or difficult breathing, assess for diarrhoea,
assess for ear problem, check for malnutrition and anaemia, and then:
ASK: HAS THE CHILD or MOTHER BEEN TESTED FOR HIV INFECTION?
YES, test results available
NO test results available
Assess for HIV infection
Check for features of HIV
CLASSIFY the child using the colour-coded charts
Check immunization status, assess feeding, other problems and mother’s health
24
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
HOW WILL YOU ASSESS FOR HIV INFECTION?
THEN CHECK
INFECTION
Open to your ASSESS
chart forFOR
HIV.HIV
It contains
these instructions, starting with
Use this chart if the child is NOT already enrolled in HIV care. If already enrolled in HIV care, go to the next step an
ASK:
ASK
Has the mother and/or IF YES: Then note
child had an HIV test? mother's and/or child's
HIV status:-
Classify
HIV
status
Mother's HIV
status: POSITIVE or
NEGATIVE
Child's HIV status:
Virological test
POSITIVE or NEGATIVE
Serological test
POSITIVE or NEGATIVE
IF NO: Mother and child
status unknown, then TEST
mother.
If positive, then test the
child.
If mother is HIV positive and child is negative or
unknown, ASK:
Was the child breastfeeding at the time or 6 weeks
before the test?
Is the child breastfeeding now?
If breastfeeding ASK: Is the mother and child on ARV
prophylaxis?
Positive viro
child
OR
Positive ser
a child 18 m
Mother HIV
negative vir
child breast
only stoppe
weeks ago
O
Mother HIV
not yet test
O
Positive ser
a child less
old
Negative HI
or child*
* Give cotrimoxazole prophylaxis to all children less than 1 year old and to children 1- 4 years old at WHO clinical s
If virological
negative,
repeat
testof
6 weeks
the breatfeeding has stopped; if serological test is positiv
On the following** pages,
you test
willislearn
about
each
theseafter
instructions.
ASK: HAS THE MOTHER AND/OR THE CHILD HAD AN HIV TEST?
Remember that this is sensitive information, and that it is important to ensure
confidentiality.
All mothers should have been offered testing during their pregnancy. Ask the mother
if she has had an HIV test. If the mother has had a test, ask her what the result was.
YES the mother or child has had an HIV test. Record the test results:
1. Mother’s HIV status: POSITIVE or NEGATIVE
Remember that a mother may have tested negative in the past, and could now
be HIV infected. The more recent the test, the more likely it is to be accurate.
2. Child’s HIV status:
a. Virological test POSITIVE or NEGATIVE
b. Serological test POSITIVE or NEGATIVE
25
Page 11 of IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
NO test result is available for mother or child. Conduct an HIV test:
If there is no test available, you will test the mother. If the test is POSITIVE, then
test the child. You learned in Section 3 of this module about the types of HIV tests
available in your country. Remember tests are different depending on the child’s age:
•• child 18 months or older: you will use a serological test. If the test is positive
it confirms the child’s status as HIV-infected.
•• child under 18 months: a virological test (PCR) is the only reliable method to
determine the child’s HIV status. It detects the actual virus in the child’s blood.
IF MOTHER IS HIV POSITIVE AND CHILD IS NEGATIVE OR UNKNOWN
In this situation, you must ask more about the child’s feeding status. You remember
that breast milk can transmit HIV. As a result, a child who has initially tested
negative may still develop HIV infection.
It is therefore important to know if the child was breastfeeding or had been breastfed
in the six weeks before the test was done. Six weeks is considered the “window
period” or time during which a patient may test negative even though they
are infected.
In order to better understand the child’s feeding status, you will ask the following
questions and record responses:
1. If a previous test was done, was the child breastfeeding at the time or the test?
Was the child breastfeeding in the 6 weeks before the test?
2. Is the child breastfeeding now?
3. If the child is breastfeeding, ASK: is the mother and child on ARV prophylaxis?
You will learn more about ARV prophylaxis in section 9.6.
REMEMBER! Child must not have breastfed within six weeks of a test in
order for it to be confirmed negative.
26
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
WITH HIV RESULTS AVAILABLE, CLASSIFY THE CHILD:
Once you have the child or mother’s test results, you can classify according to the
result. Open to the classification table. There are three classifications:
1. CONFIRMED HIV INFECTION
2. HIV EXPOSED
3. HIV INFECTION UNLIKELY
already enrolled in HIV care, go to the next step and assess for mouth and gum condition.
Classify
HIV
status
Positive virological test in
child
OR
Yellow:
CONFIRMED HIV
INFECTION
Give cotrimoxazole prophylaxis*
Give HIV care and initiate ART treatment
Assess the child’s feeding and provide
appropriate counselling to the mother
Advise the mother on home care
Positive serological test in
a child 18 months or older
Refer for TB assessment and INH preventive
therapy
Follow-up regularly as per national guidelines
Mother HIV-positive AND
negative virological test in
child breastfeeding or if
only stopped less than 6
weeks ago
Yellow:
HIV EXPOSED
Give cotrimoxazole prophylaxis
Start or continue ARV prophylaxis as
recommended
Do virological test to confirm HIV status**
Assess the child’s feeding and provide
appropriate counselling to the mother
Advise the mother on home care
Follow-up regularly as per national guidelines
Green:
HIV INFECTION
UNLIKELY
Treat, counsel and follow-up existing infections
OR
Mother HIV-positive, child
not yet tested
OR
Positive serological test in
a child less than 18 months
old
Negative HIV test in mother
or child*
* If mother’s or child’s HIV status is unknown, offer HIV testing for mother and then for child or if mother is not available,
offer HIV testing for child.
old and to children 1- 4 years old at WHO clinical stages 2, 3 and 4 regardless of CD4 percentage or at any WHO stage and CD4 <25%
CONFIRMED
INFECTION
eatfeeding has stopped; if serological
test is positive, doHIV
a virological
test as soon(YELLOW)
as possible.
A child with a positive HIV test should be classified as CONFIRMED HIV
INFECTION. This means a positive serological test for a child 18 months or older.
Virological tests confirm HIV in all children. These children should be provided
cotrimoxazole prophylaxis (you will learn about eligibility in 9.6), HIV care and
ART, and other counselling.
HIV EXPOSED (YELLOW)
Children born to HIV-positive women are HIV EXPOSED and could possibly have
HIV. This classification is used for three different scenarios:
1. Mother is HIV-positive and the child has a negative virological test, but the child
is still breastfeeding or stopped less than 6 weeks ago. Due to the breastfeeding,
the child still risks exposure, or the negative status cannot yet be confirmed.
Page 11 of 75 2. Mother is HIV-positive and child has not yet tested.
3. The child is less than 18 months old and has a positive serological test. Remember
that this child’s status can only be confirmed with a virological test.
27
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
These children require cotrimoxazole prophylaxis and ARV prophylaxis (as
recommended). The child should receive a virological test to confirm status.
If this test is negative, it must be repeated after breastfeeding has stopped for 6
weeks in order to be confirmed.
HIV INFECTION UNLIKELY (GREEN)
If mother or child has a negative test, the child is classified HIV NEGATIVE. You will
treat, counsel, and follow-up existing conditions according to your IMCI assessment.
SELF-ASSESSMENT EXERCISE C – ASSESS & CLASSIFY SICK CHILD
Are these statements about assessing and classifying true or false?
a. A 10-month old has a positive virological test. She stopped
breastfeeding 30 days ago. She should be classified as
CONFIRMED HIV INFECTION.
b.A 9 month old child is still breastfeeding has tested
negative with a PCR test. He should be classified as HIV
INFECTION UNLIKELY.
c. A 9 week old child is clinically well. His mother is HIVinfected. The child has not been tested yet, so you conduct
a serological test. The result is positive. He should be
classified as CONFIRMED HIV INFECTION.
d.You send for a PCR test for a 16 month old. The results
are positive. He stopped breastfeeding when he was 12
months old. He should be classified as CONFIRMED HIV
INFECTION.
e. A 4 month old was born to an HIV-infected mother. He is
breastfeeding. You provide a serological test, and the result
is positive. He should be classified as HIV EXPOSED.
f. An 8 month old child born to an HIV-infected mother
comes to the clinic. Her mother says she was tested
2 months ago. You see the PCR results, and they are
negative. The child is still breastfeeding. She should be
classified as HIV INFECTION UNLIKELY.
g. A 36 month old child has a positive serological HIV test.
She should be classified as CONFIRMED HIV INFECTION.
28
TRUE
FALSE
TRUE
FALSE
TRUE
FALSE
TRUE
FALSE
TRUE
FALSE
TRUE
FALSE
TRUE
FALSE
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
n How will you assess Peter for HIV?
First, you review the ASSESS table in the sick child charts. You ask Lungile is Peter is breastfeeding. She says
yes. She has also already told you that she has been tested for HIV and is infected. She did not receive any
ART prophylaxis for PMTCT.
You
ask
has
been
tested,forand
sheand
says
You counsel Lungile on testing Peter for HIV, and the
already enrolled in HIV
care,
goiftoPeter
the next
step
and assess
mouth
gumno.
condition.
Classify
HIV
status
importance of identifying children who are exposed or infected with HIV. You provide a serological test. The
Yellow:
Positive virological test in
Give cotrimoxazole prophylaxis*
result is positive.
child
OR
n How willPositive
you classify
Peter?
serological test in
CONFIRMED HIV
INFECTION
Give HIV care and initiate ART treatment
Assess the child’s feeding and provide
appropriate counselling to the mother
Advise the mother on home care
a child 18 months or older
Lungile is HIV positive,
and Peter has a negative serologicalRefer
test.for
HeTBisassessment
6 monthsand
old.INH
You
classify him as HIV
preventive
EXPOSED.
therapy
Follow-up regularly as per national guidelines
Mother HIV-positive AND
negative virological test in
child breastfeeding or if
only stopped less than 6
weeks ago
Yellow:
HIV EXPOSED
Give cotrimoxazole prophylaxis
Start or continue ARV prophylaxis as
recommended
Do virological test to confirm HIV status**
Assess the child’s feeding and provide
appropriate counselling to the mother
Advise the mother on home care
Follow-up regularly as per national guidelines
Green:
Treat, counsel and follow-up existing infections
OR
Mother HIV-positive, child
not yet tested
OR
Positive serological test in
a child less than 18 months
old
Negative HIV test in mother
or child*
HIV INFECTION
Remember that
you cannot confirm Peter’s
HIV status until he has stopped breastfeeding for at least
UNLIKELY
6 weeks. His status must be confirmed with a virological test as long as he is under 18 months of age.
In section 6 you will learn how to give prophylaxis to Peter. In section 7 you will learn about feeding
recommendations for Peter. In section 8 and subsequent sections you will learn about follow-up care,
ART
initiation
if the2,child
confirmed
positive.
Withorthe
classification
HIVCD4
EXPOSED,
old and to children 1- including
4 years old at
WHO
clinical stages
3 and is
4 regardless
of CD4
percentage
at any
WHO stage and
<25% Peter will
follow-up
with
monthly.
eatfeeding has stopped;
if serological
testyou
is positive,
do a virological test as soon as possible.
SUMMARY: WHAT DID YOU LEARN IN THIS SECTION?
1.You will use HIV test results from a child and mother to assess and
classify a child’s HIV status. You will use test results from a mother and/
or child to classify the child’s HIV status. The first course of action is to test
the mother if you do not have her test results. If she is positive, then you will
test the child. It is important to maintain confidentiality of the test results of
mothers and children. If the HIV status of the mother or child is unknown, the
care provider should offer HIV testing especially if the child has malnutrition,
pneumonia, diarrhoea, chronic cough or other symptoms that may suggest HIV/
AIDS. This is referred as provider-initiated testing and counseling.
Page 11 of 75 can be infected with HIV while breastfeeding. Test results cannot
2. Children
be confirmed unless the child has not breastfed for 6 weeks or more. This is an
important window.
29
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
3. Virological tests must be used to confirm the status of a child under 18
months. Children under 18 months require confirmation by PCR (virological)
testing. Remember it is different for children older than 18 months: these
children can be confirmed with a serological test. The second important point
is that test results cannot be confirmed unless the child has not breastfed for 6
weeks or more.
30
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
8.5
ASSESS & CLASSIFY A SICK YOUNG INFANT
What are the learning objectives for this section?
•• Explain how assessing and classifying for HIV is different for a young infant
•• Assess and classify a young infant using the chart booklet
WHEN WILL YOU ASSESS AND CLASSIFY A YOUNG INFANT FOR HIV?
Review what you have learned so far about assessing and classifying the sick young
infant.
For ALL sick young infants – ask the caretaker about the infant’s problems,
check for signs of possible bacterial infection and jaundice, assess for diarrhoea, then:
ASK: HAS INFANT BEEN TESTED FOR HIV?
YES
NO
Assess for HIV infection
Assess based on mother’s status
CLASSIFY the young infant’s HIV status using the colour-coded charts
NEXT: assess for feeding problems or low weight, check immunizations,
consider special risk factors, and assess mother’s health and other problems
HOW IS ASSESSING AND CLASSIFYING A YOUNG INFANT
DIFFERENT THAN A CHILD?
Assessing and classifying the sick young infant for HIV differs from the
classification for an older child. It is not possible to classify the sick young infant
for SYMPTOMATIC HIV INFECTION because infants usually do not show signs
and symptoms of HIV like children.
Young infants with HIV infection usually do not have any
signs and symptoms directly related to HIV infection –
this does not mean that they may not become ill, but rather that
they will develop signs and symptoms of common childhood
illnesses such as pneumonia or diarrhoea. As a result, the
assessment and classification of HIV infection in young infants
is based on HIV test results.
31
Young infants usually do
not have signs directly
related to HIV.
As a result, classifications
use HIV test results.
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
WHY IS EARLY IDENTIFICATION SO IMPORTANT WITH
YOUNG INFANTS?
It is very important that young infants with HIV are identified early. These infants
may look well, but can become ill and die very quickly. PCR virological testing is
now available in many regions – this helps to identify HIV-infected children
early. All children born to HIV-infected mothers should be tested for HIV infection
using a virological test.
We have to ensure that all exposed babies are identified and tested, and that test
results come back to the clinic and are communicated to the caregiver. Counselling
of the mother or caregiver before and after the test is a key part of this process.
Early identification allows the infant to benefit from ART and other treatments.
HOW WILL YOU ASSESS THE YOUNG INFANT FOR HIV?
Review the ASSESS chart. What instructions do you see?
ASSESS YOUNG INFANT FOR HIV ASK: HAS THE MOTHER AND/OR YOUNG INFANT HAD AN HIV TEST?
YES test available: note the mother’s and/or young infant’s HIV status
1. Mother’s HIV status: serological test POSITIVE or NEGATIVE
Remember that a mother may have tested negative in the past, and could now be HIV
infected. The more recent the test, the more likely it is to be accurate.
2. Young infant’s HIV status:
a. Virological test POSITIVE or NEGATIVE
b. Serological test POSITIVE or NEGATIVE
32
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
If mother is positive and no positive virological test in child, ASK about
feeding status:
As you know, the child’s status cannot be confirmed until breastfeeding has stopped
for at least 6 weeks. Therefore you should ask the mother this important information:
•• Is the young infant breastfeeding now?
•• Was the young infant breastfeeding at the time of the test or before it?
•• Are the mother and young infant on ARV prophylaxis?
NO test available, so mother and young infant status unknown:
If the mother and young infant test results are not known, you will perform an HIV
test for the mother. If it is positive, perform a virological test for the young infant.
HOW WILL YOU CLASSIFY THE YOUNG INFANT FOR HIV?
After you ASSESS for rest results, you will classify. There are three classifications:
1. CONFIRMED HIV INFECTION
2. HIV EXPOSED
3. HIV INFECTION UNLIKELY
already enrolled in HIV care, go to the next step and assess for mouth and gum condition.
Classify
HIV
status
Positive virological test in
child
OR
Yellow:
CONFIRMED HIV
INFECTION
Give cotrimoxazole prophylaxis*
Give HIV care and initiate ART treatment
Assess the child’s feeding and provide
appropriate counselling to the mother
Advise the mother on home care
Positive serological test in
a child 18 months or older
Follow-up regularly as per national guidelines
Mother HIV-positive AND
negative virological test in
child breastfeeding or if
only stopped less than 6
weeks ago
Yellow:
HIV EXPOSED
Give cotrimoxazole prophylaxis
Start or continue ARV prophylaxis as
recommended
Do virological test to confirm HIV status**
Assess the child’s feeding and provide
appropriate counselling to the mother
Advise the mother on home care
Follow-up regularly as per national guidelines
Green:
HIV INFECTION
UNLIKELY
Treat, counsel and follow-up existing infections
OR
Mother HIV-positive, child
not yet tested
OR
Positive serological test in
a child less than 18 months
old
Negative HIV test in mother
or child*
* If mother’s or child’s HIV status is unknown, offer HIV testing for mother and then for child or if mother is not available,
offer HIV testing for child.
old and to children 1- 4 years old at WHO clinical stages 2, 3 and 4 regardless of CD4 percentage or at any WHO stage and CD4 <25%
eatfeeding has stopped; if serological
test is positive, doHIV
a virological
test as soon(YELLOW)
as possible.
CONFIRMED
INFECTION
If the young infant has a positive virological (PCR) test, she is classified as
CONFIRMED HIV INFECTION. Remember that a virological test must be used
because a serological test does not confirm HIV infection in children less than
18 months of age. Children with this classification should receive cotrimoxazole
prophylaxis from age 4–6 weeks. All young infants with CONFIRMED HIV
33
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
INFECTION are eligible to receive ART and HIV care. You will learn about this in
the upcoming sections of this module.
HIV EXPOSED (YELLOW)
The young infant is classified as HIV EXPOSED if one of the following scenarios
is true:
•• If the mother is HIV-infected and the young infant’s virological is negative, but
he is still breastfeeding or stopped breastfeeding less than 6 weeks ago. The
infant is still exposed to HIV during breastfeeding.
•• If the mother is HIV infected and no test result is available for the infant.
•• If the infant has a positive serological test.
The HIV EXPOSED child should receive cotrimoxazole prophylaxis from age 4–6
weeks. ARV prophylaxis should be given per national recommendations. Remember
that the child’s status must be confirmed after he has stopped breastfeeding for
at least 6 weeks.
HIV INFECTION UNLIKELY (GREEN)
The child is classified HIV INFECTION UNLIKELY if the mother has a negative HIV
test, or the young infant has a negative test and was not breastfed for six weeks
before the test was done. These infants can be followed up routinely. Cotrimoxazole
prophylaxis can be stopped, if it had been previously started.
SELF-ASSESSMENT EXERCISE D – CLASSIFY
Classify the following sick young infants and children for HIV status.
1. 7 week old child. Mother HIV-positive.
2. 8 week old girl. Abandoned at birth, now formula feeding.
PCR done at six weeks was negative.
3. 6 week old with positive PCR test.
4. 7 week old, status unknown. Mother tested negative.
5. 12 month old, status unknown. Grandmother brings child to
clinic. Child has positive serological test.
SUMMARY: WHAT DID YOU LEARN IN THIS SECTION?
1. If the mother and young infant do not have test results, you will begin
by testing the mother.
If the mother is HIV positive, this means the young infant has been exposed.
You will then test the young infant. If the mother is HIV negative, HIV infection
in the young infant is unlikely.
2. Young infants can be infected with HIV while breastfeeding.
Test results cannot be confirmed unless the young infant has not breastfed for
6 weeks or more. This is an important window.
34
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
3. Virological tests must be used to confirm the status of young infant.
Young infants are under two months of age. You remember that children under
18 months require confirmation by PCR (virological) testing.
4. Any child or young infant with symptoms suggestive of HIV infection,
offer HIV testing.
35
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
8.6
PROPHYLAXIS AND OTHER PREVENTIVE
MEASURES
What are the learning objectives for this section?
After you study this section, you will know how to prevent HIV infection and other
common illnesses in infants and young children classified for HIV by:
•• Providing prophylactic ARVs
•• Providing cotrimoxazole prophylaxis
•• Providing isoniazid preventive therapy to address TB and HIV co-infection
•• Ensuring complete immunizations
•• Providing Vitamin A supplementation and regular deworming
•• Monitor HIV-infected children to ensure timely ART initiation
WHY IS THIS CARE IMPORTANT FOR HIV-EXPOSED AND
INFECTED CHILDREN?
You learned in the introduction of this module that HIV attacks a child’s immune
system. Because of this, children and infants become very vulnerable to infections
that may not usually make them so sick.
There are many important treatments for preventing and managing these
opportunistic infections. Several types of prophylaxis and other preventive
measures seek to keep a child’s immune system strong.
WHAT TYPES OF PROPHYLAXIS ARE GIVEN?
There are a number of prophylaxis and preventive measures for children and infants
who are HIV exposed and infected.
In this section you will read about the following measures:
•• PROPHYLACTIC ARVs
•• COTRIMOXAZOLE PROPHYLAXIS
•• ISONIAZID PREVENTIVE THERAPY
These important prophylactic measures are discussed in the well child care module:
•• IMMUNIZATIONS
•• VITAMIN A SUPPLEMENTATION
WHY ARE THESE TYPES OF PROPHYLAXIS IMPORTANT?
Prophylactic ARVs (nevirapine and zidovudine prophylaxis) can help in preventing
HIV infection in young infants. The other types of prophylaxis in this list prevent and
manage common opportunistic infections like tuberculosis, pneumonia, and other
bacterial infections. Routine care like immunizations, Vitamin A, and deworming are
important measures for HIV-exposed and HIV-infected children to prevent illness.
36
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
How will you give ARV prophylaxis?
Nevirapine (NVP) or zidovudine (AZT) are provided to HIV-exposed infants to
minimize mother-to-child transmission of HIV (PMTCT) until 4 to 6 weeks of age.
Open your chart booklet to the ‘TREAT’ charts to find instructions for PMTCT
prophylaxis:
BREASTFEEDING
REPLACEMENT FEEDING
6 weeks of infant prophylaxis
with once-daily NVP
4–6 weeks of infant prophylaxis with
once-daily NVP (or twice-daily AZT)
It is important to note that if a mother is found to be positive very late in pregnancy,
during labour, or during breastfeeding, and begins ART at this time, the ARV
prophylaxis for the child might need to be extended to 12 weeks.
The recommendations above are for both Option B+ and Option B PMTCT national
policies. The Option B+ policy says that every HIV-infected pregnant or breastfeeding
woman in high HIV settings should receive triple ART during this period, and
then continue on lifelong ART. The Option B policy says that HIV-infected women
receiving ART will stop at the end of breastfeeding transmission risk.
WHAT IS THE DRUG DOSAGE FOR PMTCT PROPHYLAXIS
IN YOUNG INFANTS?
The same ‘TREAT’ chart for PMTCT prophylaxis includes dosing information for
NVP and AZT. There are very important points about prophylaxis:
✔✔ Consider the infant’s birth weight if under 6 weeks old
✔✔ Monitor the infant’s age and change dosing as they age
What is cotrimoxazole prophylaxis?
Regular prophylaxis with Trimethoprim-sulfamethoxazole (TMP/SMX), also known
as cotrimoxazole, provides a simple, inexpensive, and effective strategy to prevent
illness. Cotrimoxazole prophylaxis provided to children with suspected or confirmed
HIV infection will decrease sickness and death due to PCP, other common bacterial
infections, and malaria.
WHY IS COTRIMOXAZOLE PROPHYLAXIS IMPORTANT?
Cotrimoxazole prophylaxis can reduce the mortality of HIV-infected children by
up to 40%. Infants and children with suspected or confirmed HIV infection may
acquire severe pneumonia and other serious infections at an early age. Often this
occurs before their HIV status has been confirmed.
Cotrimoxazole prophylaxis is given to HIV-exposed and infected children to
reduce the risk of infection, and lower mortality.
37
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
One serious life-threatening form of pneumonia is caused by an organism called
pneumocystis jirovecii (previously carinii). This is commonly called PCP. This is a
common cause of death in HIV-infected children, in particular young infants. The
risk of PCP is decreased if the child takes regular daily cotrimoxazole prophylaxis.
WHO SHOULD RECEIVE COTRIMOXAZOLE PROPHYLAXIS?
The table below reviews when certain classifications of infants and children should
begin cotrimoxazole.
THESE YOUNG INFANTS…
SHOULD START…
WHY?
CONFIRMED HIV INFECTION
From 4–6 weeks
Infant is HIV infected
HIV EXPOSED
From 4–6 weeks
Infant is born to HIV infected mother and exposed to HIV
THESE CHILDREN…
SHOULD START…
WHY?
CONFIRMED HIV INFECTION
Less than 12 months old
As soon as possible
Child is HIV infected
CONFIRMED HIV INFECTION
12 months up to 5 years
These children are eligible:
1. When at WHO clinical stages
2-3-4, regardless of CD4%
2. When CD4% less than 25%,
no matter what stage
Refer to Annex 1 to learn about
staging.
This is regardless of whether the child is on ART or not.
HIV EXPOSED
As soon as possible
Child is exposed to HIV
Over 5 years of age
Follow adult guidelines
Children in this age category use adult prophylaxis
guidelines.
WHAT DOSE OF COTRIMOXAZOLE WILL YOU GIVE FOR
PROPHYLAXIS?
The details for cotrimoxazole prophylaxis in HIV-exposed and infected children
and infants are summarized below.1 You can also review in your TREAT charts,
TREAT WITH ORAL ANTIBIOTIC. See Annex 2 for a more information on dosing.
NOTE that if the HIV-infected child qualifies for cotrimoxazole and ART
simultaneously, start cotrimoxazole first.
COTRIMOXAZOLE DOSAGE – SINGLE DOSE PER DAY
Drug: Cotrimoxazole (Trimethoprim-sulfamethoxazole or TMP/SMX)
Syrup
40 mg TMP/200 mg SMX per 5 ml
Adult Tablet Single Strength
80 mg TMP/400 mg SMX
Paediatric Tablet Single Strength
20 mg TMP/100 mg SMX
Less than 6 months
2.5ml
–
1 tablet
6 months up to 5 years
5 ml
1/2 tablet
2 tablets
5 to 14 years
10 ml
1 tablet
4 tablets
Over 15 years
NIL
2 tablets
–
Age
Revised WHO guidelines for cotrimoxazole prophylaxis in HIV-exposed and HIV-infected children in resourcelimited countries, Geneva, May 10–12, 2005.
1
38
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
HOW LONG DO CHILDREN RECEIVE COTRIMOXAZOLE
PROPHYLAXIS?
Cotrimoxazole prophylaxis is one of the medications an exposed or infected child
will need to take for a long time. Even with increasing access to ART, cotrimoxazole
prophylaxis is very important.
NOTE that it is recommended that infants with confirmed HIV infection
in resource-limited settings should continue cotrimoxazole indefinitely.
WHEN SHOULD COTRIMOXAZOLE PROPHYLAXIS BE STOPPED?
•• HIV IS RULED OUT
When children and infants classified as HIV EXPOSED are confirmed HIVnegative, and the mother is no longer breastfeeding
•• SEVERE DRUG REACTIONS
Severe toxicity can include Steven Johnson syndrome or severe pallor. This child
should be referred to second level for assessment and for an alternate drug. If
you are unsure about whether to stop cotrimoxazole, refer the child to second
level for assessment and advice.
HOW CAN A HEALTH WORKER SUPPORT ADHERENCE TO
COTRIMOXAZOLE?
To make sure the caretaker and/or child are able to adhere to cotrimoxazole, they
will need counselling and support. Several counselling sessions will be required in
order to ensure that the issue of prophylaxis has been discussed with the caretaker
and that they have fully understood and agreed to adhere to the treatment. You
will learn more about chronic follow-up care for HIV-infected children in Section
11 of this module.
39
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
SELF-ASSESSMENT EXERCISE E – COTRIMOXAZOLE
Answer the following questions about cotrimoxazole prophylaxis.
1. What children should receive cotrimoxazole prophylaxis?
2. At what age should cotrimoxazole prophylaxis be started?
3. What are possible serious side effects of cotrimoxazole prophylaxis?
4. Should the following infants be receiving cotrimoxazole? If they should be
receiving it, write down the correct dose in the last column.
Should child receive cotrimoxazole?
If YES, what
is the daily dose?
a. 6 week HIV-exposed girl, PCR not
available yet
 YES  NO
.......................
b. 6 month old HIV-exposed girl. PCR
positive, not yet on ART.
 YES  NO
.......................
c. 7 month old HIV-exposed girl. PCR
negative at 6 months of age. Stopped
breastfeeding at 3 months.
 YES  NO
.......................
d. 4 month old boy who started on
ART today
 YES  NO
.......................
e. 2 week old boy, HIV exposed, PCR
test not sent yet
 YES  NO
.......................
f. 8 month old HIV-exposed boy, breastfeeding. PCR negative when tested at
six weeks.
 YES  NO
.......................
g. 3 year old girl, clinical stage 3
 YES  NO
.......................
h. 2 month old girl with SEVERE
PNEUMONIA, and has tested PCR
positive.
 YES  NO
.......................
i. 9 month old boy classified as HIV
EXPOSED. His caregiver declines testing.  YES  NO
.......................
j. 4 year old boy with HIV infection,
CD4% is 45%
.......................
 YES  NO
5. When should cotrimoxazole prophylaxis be stopped?
40
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
WHAT IS ISONIAZID PREVENTIVE THERAPY (IPT)?
IPT is an important intervention for preventing and reducing active tuberculosis
(TB) in children living with HIV. IPT is an important part of a comprehensive
package of care for children and infants living with HIV. IMPORTANT NOTE:
You will initiate IPT in your facility only if your facility can do investigations to
identify tuberculosis cases.
WHY IS IPT FOR HIV-INFECTED CHILDREN AND INFANTS
IMPORTANT?
TB is a major cause of illness and death in children living with HIV. This is even
true in children who are on ART. Increasing levels of co-infection with TB and
HIV in children have been reported from resource-limited countries. Of children
infected with TB living in resource-limited countries, 10% to 60% are also
infected with HIV.
HIV infection has an impact on the entire cycle of TB infection and disease. HIV
increases a child’s susceptibility to tuberculosis infection, it increases the risk of
rapid progression to TB disease, and it increases the risk of TB reactivation in older
children with latent TB.
WHO SHOULD RECEIVE ISONIAZID PREVENTIVE THERAPY?
You will only consider isoniazid preventive therapy for children and infants who
are confirmed with HIV infection. IPT is also identified in your HIV classification
tables in the TREATMENT column.
IF THE HIV-INFECTED INFANT or CHILD IS:
ACTIONS TO TAKE:
EXPOSED TO TB
This means the child has been exposed to TB through
household contacts, but has no evidence of active disease.
Begin IPT for 6 months. See next page for dosage of isoniazid
(INH) for preventive therapy in HIV co-infections.
NOT EXPOSED TO TB
This includes children over 12 months living with HIV,
including those previously treated for TB, who are not likely
to have active TB and are not known to be exposed to TB.
Begin IPT for 6 months. This is part of a comprehensive
package of HIV care. See next page for dosage.
DIAGNOSED WITH TB
This includes any child with active TB disease
1.Begin TB treatment immediately
2.Start ART as soon as tolerated within the first 8 weeks of
TB therapy, no matter the CD4 count and clinical stage
WHAT IS THE DOSAGE FOR ISONIAZID PREVENTIVE THERAPY?
The recommended dose of isoniazid (INH) for preventive therapy in HIV coinfections is a daily dose of 10 mg per kg, with a maximum daily dose of 300 mg/
day. This dosage is given for 6 months. See Annex 2 for a more information on
dosing.
DOSE: 10 mg/kg (maximum daily dose 300 mg)  for 6 months
41
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
How will you give immunizations to HIV-exposed
and infected infants?
You have learned about giving immunizations in MODULES 2 and 7. You should
also always follow the national guidelines for immunizations. However, there are
important differences specific for infants who are HIV-exposed or infected.
GIVE ROUTINE EPI VACCINES ACCORDING TO NATIONAL SCHEDULES
All HIV-exposed infants and children should receive all EPI vaccines, including Hib
and pneumococcal vaccine, as early in life as possible, according to the recommended
national schedule.
POSSIBLE ADDITIONAL DOSE OF HIB
Haemophilus influenza type b (Hib) has been shown to be an important cause
of childhood meningitis and a major cause of bacterial pneumonia in children.
HIV appears to be a risk factor for developing invasive disease due to H. influenzae
type B, especially bacteremic pneumonia. Hib vaccine is recommended for use in
national childhood immunization programmes in all countries, including in HIVinfected children. The vaccine is generally administered along with DTP vaccines
during infancy.
The need and timing for an additional dose in the second year of life in children
in developing countries is not well-defined. However, an additional dose may be
particularly useful in HIV-infected children even in developing countries.
BCG VACCINATION
New findings indicate a high risk of disseminated BCG disease developing in HIVinfected infants. However, it is difficult to identify infants infected with HIV at
birth. Therefore, the BCG vaccination may need to be given at birth to all infants
regardless of HIV exposure, in areas with high endemicity of tuberculosis and
populations with high HIV prevalence.
YELLOW FEVER
Infants with symptomatic HIV infection should NOT receive yellow fever vaccines.
DO NOT VACCINATE SEVERELY ILL CHILDREN
As for any severely ill child at the time of immunization, severely ill HIV-infected
children should NOT be vaccinated.
How will you provide Vitamin A supplementation?
Young infants and children infected with HIV should follow the same Vitamin A
supplementation protocol as for uninfected young infants and children. It is best
that the Vitamin A doses are synchronised with immunization visits or campaigns.
Remember to make sure that children with HIV infection also receive routine
deworming treatments. This is further described in the module on well child care.
42
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
SELF-ASSESSMENT EXERCISE F – INTEGRATED TREATMENT
You will again practice integrated treatment, a skill you have learned throughout
your modules. In the cases below, the child also has an HIV-related classification.
How will you treat or follow-up?
1. How would you treat a child with the classifications: HIV EXPOSED and
PNEUMONIA?
2. When should you follow-up a child with the classifications: PERSISTENT
DIARRHOEA and HIV EXPOSED?
3. How would you treat a child with the classifications: PNEUMONIA (wheeze
present) and HIV EXPOSED?
4. How would you treat a child with the classifications: PERSISTENT DIARRHOEA
and CONFIRMED HIV INFECTION? The child’s father has active TB and has
just begun treatment.
5. How would you treat a child with the classifications: PNEUMONIA, CHRONIC
EAR INFECTION, COMPLICATED SEVERE ACUTE MALNUTRITION, and
CONFIRMED HIV INFECTION?
43
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
n Now you will return to Peter. What will you do during your first visit?
During your first visit with Peter, you classified him with PNEUMONIA and HIV EXPOSED. These are both
yellow. You identify treatments in your chart booklet:
PNEUMONIA
Yellow
• Give oral amoxicillin for 5 days
• If wheezing (even if it disappeared after
rapidly acting bronchodilator) give an inhaled
bronchodilator for 5 days**
• Soothe the throat and relieve the cough with a
safe remedy
• If coughing for more than 2 weeks or if having
recurrent wheezing, refer for assessment for TB
or asthma
• Consider HIV infection
• Advise mother when to return immediately
• Follow-up in 3 days
• Give cotrimoxazole
prophylaxis
• Start or continue ARV as
recommended
• Do virological test to
confirm HIV status**
• Assess the child’s feeding
and provide appropriate
counseling to the mother
• Advise the mother on home
care
• Follow-up regularly
HIV
EXPOSED
Yellow
EPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART
You know that Peter requires an oral antibiotic for pneumonia, and cotrimoxazole for HIV exposure. Your first
step is to manage these two treatments.
1. Amoxycillin: Peter requires an appropriate oral antibiotic for 5 days for PNEUMONIA. He will receive
OME
for 5Appropriate
days at the appropriate
dosage
for a six month old. This is indicated by the arrow. You
Give
an
Antibiotic
be given
at amoxycillin
TEPS
IDENTIFIED
ON
THE
ASSESSOral
AND
CLASSIFY
CHART
will assess Peter’s cough again during the follow-up visit in 3 days.
FOR PNEUMONIA, ACUTE EAR INFECTION:
FIRST-LINE ANTIBIOTIC: Oral Amoxicillin
dosage table.
HOME
or weight.
to be given at
AMOXICILLIN*
Give two times daily for 5 days for PNEUMONIA and ACUTE EAR INFECTION
WEIGHT
Give AGE
anorAppropriate
OralTABLET
Antibiotic
g's dosage table.
he
ge drug.
or weight.
ach drug
nish the course of
e the drug.
e each drug
FOR PNEUMONIA, ACUTE EAR INFECTION:
2 months up to 12 months (4 - <10 kg)
FIRST-LINE ANTIBIOTIC: Oral Amoxicillin
12 months up to 3 years (10 - <14 kg)
SYRUP
250mg/5 ml
250 mg
1
5 ml
2
10 ml
AMOXICILLIN*
3 years up to 5 years (14-19 kg)
3
15 ml
Give two times daily for 5 days for PNEUMONIA and ACUTE EAR INFECTION
* Amoxicillin is now
the
first-line
drug
of
choice
in
the
treatment
of
pneumonia
due
to its efficacy and increasing high resistance
AGE or WEIGHT
TABLET
SYRUP
to cotrimoxazole .
mg
250mg/5 ml
FOR PROPHYLAXIS, CONFIRMED HIV OR HIV EXPOSED250
CHILD:
ANTIBIOTIC
FOR PROPHYLAXIS:
Cotrimoxazole
2 months
up to 12 monthsOral
(4 - <10
kg)
1
5 ml
2. Cotrimoxazole prophylaxis: After Peter completes
5 days of oral antibiotics for pneumonia, you
12 months up to 3 years (10 - <14 kg)
2COTRIMOXAZOLE
10 ml
determine he
needs
further
antibiotic
treatment(trimethoprim
for
cause. If he does not,
+ sulfamethoxazole)
3 years
up to
5 years (14-19
kg)
3 another
15 ml he can begin
Give
once
aappropriate
day starting
at 4-6daily
weeks
of
to: a 6
cotrimoxazole
prophylaxis
for HIV
exposure.
The
for
month
old
isresistance
indicated
* Amoxicillin
is now the first-line
drug
of choice
in the
treatment
of pneumonia
duedose
to age
its efficacy
and
increasing
high
All infants HIV exposed untill definitly ruled out
to cotrimoxazole .
with the arrow:
AGE
All infants with confirmed HIV infection aged < 12 months or those with stage 2, 3 or 4 disease
o finish the course of
FOR PROPHYLAXIS, CONFIRMED HIV OR HIV EXPOSED CHILD:
ANTIBIOTIC FOR PROPHYLAXIS: Oral Cotrimoxazole All infants or children with CD4 < 25%
Syrup
(40/200 mg/5ml)
c.
Paediatric COTRIMOXAZOLE
tablet
Adult tablet
(Single strength
20/100 +mg)
(Single strength 80/400 mg)
(trimethoprim
sulfamethoxazole)
Less than 6 months
2.5 ml
Give once a1day starting at 4-6 weeks of age to:
6 months up to 5 years
5 ml
2 exposed untill definitly ruled out 1/2
All infants HIV
AGE give Ciprofloxacine
FOR DYSENTERY
All infants with confirmed HIV infection aged < 12 months or those with stage 2, 3 or 4 disease
FIRST-LINE ANTIBIOTIC: Oral Ciprofloxacine
All infants or children with CD4 < 25%
CIPROFLOXACINE
Syrup
Paediatric tablet
Adult tablet
AGE
Give 15mg/kg two times daily for 3 days
(40/200 mg/5ml)
(Single
strength
(Single
strength
250 mg
tablet 20/100 mg)
500 mg
tablet 80/400 mg)
Less than
6 months
Less
than 6 months
6 months
up to 5up
years
6 months
to 5 years
3.
2.5 ml
5 ml
1
2
1/2
1
1/4
1/2 1/2
DYSENTERY give Ciprofloxacine
FORFOR
CHOLERA:
FIRST-LINEANTIBIOTIC
ANTIBIOTIC:FOR
OralCHOLERA:
Ciprofloxacine
FIRST-LINE
____________________________________________________
SECOND-LINE
ANTIBIOTIC
FORaCHOLERA:
____________________________________________________
CIPROFLOXACINE
You will
advise Lungile
on:
throat remedy,
feeding advice,
to follow-up for the PNEUMONIA
AGE
Give 15mg/kg two times daily
for 3 days
ERYTHROMYCIN
TETRACYCLINE
in 3 days, when to return for HIV test results,
and
when
to
return
immediately.
You will check
250 mg tablet
500 mg tablet
Give four times daily for 3 days
Give four times daily for 3 days
Less
than
6
months
1/2
1/4
AGE
or
WEIGHT
immunizations, vitamin A, and deworming.
6 months up to 5 years
1/2
TABLET 1
TABLET
250 mg
250 mg
FOR CHOLERA:
FIRST-LINE
____________________________________________________
2 years up toANTIBIOTIC
5 years (10FOR
- 19 CHOLERA:
kg)
1
1
SECOND-LINE ANTIBIOTIC FOR CHOLERA: ____________________________________________________
44
AGE or WEIGHT
Page 15 of 75 2 years up to 5 years (10 - 19 kg)
ERYTHROMYCIN
TETRACYCLINE
Give four times daily for 3 days
Give four times daily for 3 days
TABLET
250 mg
TABLET
250 mg
1
1
↺
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS




n What
care
will you provide when Peter returns for follow-up?
­­ 
Your classification of PNEUMONIA requires follow-up in 3 days.
€‚€
n Lungile brings Peter in 3 days for PNEUMONIA follow-up:
ƒ „
‡ˆ‰€†ˆ
You re-assess
Peter’s PNEUMONIA and do another full IMCI assessment.
…„
†
ƒ „
…„
†„
 ­
†„
€‚ƒ
„…

„‚
Peter’s breathing has slowed to 45 breaths per minute. His pneumonia is improving. You ask Lungile to
continue
giving the cotrimoxazole until it is complete. You remind her to provide additional food. You
‰‰†€†‡‹
completea
full
IMCI assessment and there are no new problems. You as happy to see that Peter is improving,
Œ „
and Lungile
is relieved. …„ care
Š
n What other
does Peter require?

‡‚

Š‚‚
You will remember that you have classified Peter as HIV EXPOSED. As Lungile is HIV-infected, you must
counsel her on feeding Peter. You will learn about this in the next section.
†„
ƒ„‚…
‚
ƒ„‚
‘
45
­
Ž
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
SUMMARY: WHAT DID YOU LEARN IN THIS SECTION?
Review the main points from this section. Reading this summary, and completing
the self-assessment exercises in the module, are important for learning.
1. Cotrimoxazole prophylaxis is very important to reducing mortality in
HIV-exposed and infected children and infants
n All young infants with confirmed HIV infection, from 4–6 weeks of age
n All young infants who are HIV-exposed, from 4–6 weeks of age
n All children who are HIV-infected and under 12 months old
n All children who are HIV-infected, from 12 months and up to 5 years of age,
who are at clinical stages 2, 3, or 4, or have a CD4% of under 25%.
n All children classified as HIV EXPOSED
2.Antiretroviral prophylaxis is an important measure in preventing
mother-to-child transmission in young exposed infants
The intervention depends on whether or not the child is breastfeeding. If the
child is breastfeeding, 6 weeks of once-daily NVP is recommended. If the child
is receiving replacement feeding, 4–6 weeks of once-daily NVP is recommended
(or twice-daily AZT).
3. Isoniazid preventive therapy is an important measure to protect children
and young infants who are HIV-infected children from tuberculosis.
Therapy lasts for 6 months. If a child has active TB they require TB treatment.
4. Routine care is critical for keeping HIV-exposed and infected infants
and children healthy
This includes timely immunizations, deworming, and Vitamin A.
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
8.7
COUNSEL HIV-INFECTED MOTHERS ABOUT
INFANT FEEDING
What are the learning objectives for this section?
After you study this section, you will know how to:
•• Explain your national guidelines on infant feeding, depending on if countries
recommend: (a) HIV-infected mothers receive ARVs while breastfeeding their
infants or (b) HIV-infected mothers should avoid all breastfeeding and use
infant milk formulas.
•• Describe feeding options for HIV exposed and infected children, including the
advantages and disadvantages of each option
•• Explain the nutritional needs of infants at different ages, and
recommendations to meet those needs: 0 to 6 months, 6 to 12 months, 12 to
24 months
WHAT FEEDING TOPICS ARE COVERED IN THIS SECTION?
This section includes a number of important discussions when considering safe
infant feeding for HIV-exposed and infected children.
1. Feeding options and considerations for HIV-infected mothers
2. Feeding recommendations for HIV-exposed children up to 24 months
a. If national recommendations are breastfeeding with ARV interventions
b. If national recommendations are no breastfeeding
3. Counselling on feeding problems that you might see in HIV-infected children
4. Counselling the mother on stopping breastfeeding
5. Counselling the mother on her own health
WHY DO HIV-INFECTED MOTHERS NEED SPECIAL COUNSELLING
AND SUPPORT?
Infant feeding counselling and support are critical for preventing mother-to-child
HIV transmission. You have learned about the risks of mother-to-child transmission
during pregnancy, labour, delivery, and through breastfeeding.
HIV-infected mothers need special counselling and support around infant feeding
and their own health. Remember that counselling on infant feeding options requires
skill and practice. This section provides you with the knowledge you will need to
give HIV-infected mothers basic information about safer infant feeding.1
This section assumes that you have completed the Counsel the Mother module of the IMCI case management
course. It does not provide you with all the skills you need to counsel pregnant or newly-delivered HIV-positive
women on infant feeding options. If you regularly need to counsel pregnant women on infant feeding options,
you should participate in one of the courses that include HIV and infant feeding counselling, for example the
WHO/UNICEF Infant and Young Child Feeding Counselling: An Integrated Course.
1
47
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
WHAT ARE IMPORTANT DEFINITIONS FOR FEEDING PRACTICES?
There are two key feeding practices to understand: exclusive breastfeeding, and
mixed feeding.
EXCLUSIVE BREASTFEEDING: giving the child breast milk and nothing more until 6 months
MIXED FEEDING: is giving the child breast milk and other foods or fluids
WHAT ARE THE FEEDING RECOMMENDATIONS FOR WOMEN WHO
DO NOT KNOW THEIR STATUS?
Women who do not know their HIV status should be encouraged to have an HIV test.
WHAT ARE THE FEEDING RECOMMENDATIONS FOR
HIV-UNINFECTED WOMEN?
All women who are HIV-negative or who do not know their HIV status should be
counselled to exclusively breastfeed their babies for the first six months of life,
then introducing complementary feeds and continuing with breastfeeding for up
to two years or beyond.
WHAT ARE THE FEEDING RECOMMENDATIONS FOR
HIV-INFECTED WOMEN?
All HIV-infected women should be informed on national recommendations for
HIV and infant feeding as part of antenatal and postnatal care. Informing mothers
about feeding recommendations can help improve HIV-free survival of HIV-exposed
infants.
WHO guidelines state that national health authorities should decide if health
services will principally counsel and support HIV-infected mothers in one of two
strategies that will most likely give infants the greatest chance of HIV-free survival:
1. BREASTFEED AND RECEIVE ARV INTERVENTIONS, OR
2. AVOID ALL BREASTFEEDING
This decision should be based on international recommendations and should
consider:
✔✔ Socio-economic and cultural contexts of the populations served by maternal
and child health services
✔✔ Availability and quality of health services
✔✔ Local epidemiology including HIV prevalence among pregnant women
✔✔ Main causes of maternal and child undernutrition, and infant and child mortality
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
WHEN POLICY RECOMMENDS MOTHER TO BREASTFEED AND
RECEIVE ART: what are important considerations when discussing
feeding options?
There are advantages and disadvantages associated with the respective infant
feeding practices available to the HIV-infected mother. These are described in the
table on the next page.
WHEN POLICY RECOMMENDS MOTHER TO BREASTFEED AND
RECEIVE ART: What happens if the mother will not breastfeed?
In exceptional circumstances when the mother cannot breastfeed or is unwilling
to breastfeed, refer to feeding counsellors.
WHAT ARE THE ADVANTAGES AND DISADVANTAGES OF THE MAIN
FEEDING OPTIONS AVAILABLE TO HIV-INFECTED MOTHERS?
The table below summarizes the major advantages and disadvantages of two feeding
practices: exclusive breastfeeding, and using commercial formula. Please read this
table to further your understanding of these feeding options. You can also discuss these
advantages and disadvantages while you counsel mothers about feeding their child.
PRACTICE
ADVANTAGES
Exclusive
What are the advantages of breast milk?
breastfeeding ✔✔ Is the perfect food for babies
✔✔ Protects babies from many serious
diseases
✔✔ Gives babies all of the nutrition and
water they need
✔✔ Is free, always available, and does not
need any special preparation
What are the advantages of exclusive
breastfeeding?
✔✔ Exclusive breastfeeding for the first few
months lowers the risk of passing
HIV, compared to mixed feeding
✔✔ People will not ask why the mother is
breastfeeding
✔✔ Exclusive breastfeeding protects the
mother from getting pregnant again
too soon
Commercial
infant
formula
What are the advantages of formula?
✔✔ Giving only formula carries no risk of
transmitting HIV to the baby
✔✔ Most of the nutrients a baby needs
have already been added to the
formula
✔✔ Others can help feed the baby
DISADVANTAGES
What are the disadvantages of exclusive breastfeeding?
✔✔ As long as a mother is breastfeeding, her baby is exposed
to HIV
✔✔ People may pressure her to give water, other liquids,
or food to the baby while she is breastfeeding. This
practice, known as mixed feeding, increases the risk of HIV
transmission, diarrhoea, and other infections
✔✔ The mother will need support to exclusively breastfeed
until it is possible for the mother to use another feeding
option
✔✔ It may be difficult if the mother works outside the home
and cannot take the baby with her
What are the disadvantages of formula?
✔✔ Formula does not contain antibodies. These are
substances that protect the baby from serious infections
✔✔ A formula-fed baby is more likely to get seriously sick
from diarrhoea, chest infections and malnutrition
✔✔ To prepare formula there is a need for a sustainable
supplies of fuel and clean water (brought to a rolling boil)
✔✔ People may wonder why the mother is not breastfeeding
✔✔ Formula takes time to prepare – bottle feeds should be
made up fresh each time
✔✔ Formula is expensive
✔✔ The mother will need support to exclusively and safely
formula feed
✔✔ Need to learn how to feed by cup
✔✔ The mother may get pregnant again too soon
49
•• DO NOT GIVE OTHER
FOODS OR FLUIDS.
Mixed feeding increases
the risk of mother-tochild HIV transmission
when compared to
exclusive breastfeeding
•• BREASTFEED as often as the
infant wants
•• BREASTFEED
EXCLUSIVELY as often
as the infant wants, day
and night. Feed at least
8 times in 24 hours.
50
Foods can include:
•• This should include protein,
and mashed fruits and
vegetables. If possible, give
an additional animal-source
food, such as liver or meat.
•• COMPLEMENTARY FOODS.
Give 3 adequate servings of
nutritious complementary
foods, plus one snack, per
day. Each meal should be ¾
cup. 1 cup = 250 ml.
6 UP TO 12 MONTHS
UP TO 6 MONTHS OF AGE
•• IF NOT BREASTFEEDING
also give about 500 ml
(1–2 cups) or full cream milk
or infant formula per day.
Give milk with a cup. Do not
use a bottle. If no milk is
available, give 4–5 feeds per
day.
•• IF BREASTFEEDING give
adequate servings of
complementary foods 3 times
per day, plus snacks.
•• COMPLEMENTARY FOODS.
Give adequate servings of
the following foods, or family
foods, 5 times a day:
12 MONTHS UP TO 2 YEARS
3. STOP BREASTFEEDING
COMPLETELY:
Express and discard enough breast
milk to keep comfortable until
lactation stops.
2. HELP MOTHER MAKE
TRANSITION:
•• Teach mother to cup feed
•• Clean all utensils with soap and
water
•• Start giving only formula or cow’s
milk once baby takes all feeds by
cup
•• Express milk and give by cup
•• Find a regular supply or formula
or other milk (e.g. full cream cow’s
milk)
•• Learn how to prepare a store milk
safely at home
1. HELP MOTHER PREPARE:
Mother should discuss and plan in
advance with her family, if possible
STOPPING BREASTFEEDING means
changing from all breast milk to none.
This should happen gradually over
one month. Plan in advance for a safe
transition.
STOPPING BREASTFEEDING
CHILDREN CLASSIFIED AS HIV EXPOSED: WHEN NATIONAL AUTHORITIES RECOMMEND BREASTFEEDING AND ARVS
This table of your CHART BOOKLET summarizes feeding recommendations for children aged 0–6 months, 6–12 months, and 12–24 months. It also reviews safe
transition from exclusive breastfeeding to replacement feeding.
WHAT ARE FEEDING RECOMMENDATIONS FOR HIV EXPOSED CHILDREN IF GUIDELINES ARE BREASTFEEDING AND ARVS?
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
REVIEWING FEEDING RECOMMENDATIONS CHART
Breastfeeding and ARVs
WHAT ARE THE KEY RECOMMENDATIONS FOR MOTHERS?
In settings where national authorities recommend breastfeeding and ARV
interventions for HIV-infected mothers, there are two scenarios: either the infants
have been confirmed with HIV infection, or they are not infected or their status
is unknown.
IF INFANTS ARE CONFIRMED HIV INFECTED:
These mothers should follow standard feeding recommendations, like any other
child. Important points in these recommendations include:
✔✔ Exclusively breastfeed infants for the first 6 months of life
✔✔ Introduce appropriate complementary foods at 6 months, and
✔✔ Continue breastfeeding up to two years or beyond – that is, as per the
recommendations for the general population
IF INFANTS ARE HIV EXPOSED:
These mothers should:
✔✔ Exclusively breastfeed infants for the first 6 months of life
✔✔ Introduce appropriate complementary foods at 6 months
✔✔ Continue breastfeeding for the first 12 months of life
✔✔ Breastfeeding should then only stop once a nutritionally adequate and safe diet
without breastmilk can be provided.
WHAT IF ARVS ARE NOT IMMEDIATELY AVAILABLE
TO THESE WOMEN?
Mothers known to be HIV-infected should be provided with lifelong antiretroviral
therapy or antiretroviral prophylaxis interventions to reduce HIV transmission
through breastfeeding according to WHO recommendations.
When antiretroviral drugs are not immediately available to HIV-infected mothers,
breastfeeding may still provide their infants with a greater chance of HIV-free
survival. In circumstances where ARVs are unlikely to be available, such as acute
emergencies, breastfeeding of HIV-exposed infants is also recommended to increase
survival.
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
WHAT ARE IMPORTANT FOR COUNSELLING HIV-INFECTED WOMEN
WHO BREASTFEED?
There are some important issues for HIV-infected women to be counselled on, and
for you to remember as a health worker.
✔✔ When HIV-positive mothers decide to stop breastfeeding at any time, infants
must be provided with safe and adequate replacement feeds to enable normal
growth and develop­ment
✔✔ Skilled counselling and support in appropriate infant feeding practices
✔✔ ARV interventions to promote HIV-free survival of infants should be available
to all pregnant women and mothers. Refer to your section on prophylaxis.
Later in this section you will review more information on counselling a
mother as she stops breastfeeding.
Refer to MODULE 2 on the sick young infant to review what you have learned about
counselling a mother on breastfeeding. When you follow-up with a mother, here
are some important items to counsel on, or check:
✔✔ Check that she breastfeeds exclusively and gives no other milk, water, or food
✔✔ Help her with any feeding problem she may report, such as “not enough milk”,
“baby crying a lot”, or sore nipples.
✔✔ Check if she breastfeeds as often as the baby wants and for as long as the baby
wants
✔✔ Observe a breastfeed and check the mother’s breasts, as required
✔✔ Check that the mother is receiving ART or ARV prophylaxis. Check drug
adherence.
✔✔ Check the health of the mother and that she has had a CD4 count in the last 6
months.
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
WHAT ARE THE FEEDING RECOMMENDATIONS FOR HIV EXPOSED CHILDREN, IF
NATIONAL GUIDELINES ARE INFANT FORMULA?
This table of your CHART BOOKLET summarizes feeding recommendations for children aged 0–6 months, 6–12
months, and 12–24 months.
CHILDREN CLASSIFIED AS HIV EXPOSED: WHEN NATIONAL AUTHORITIES
RECOMMEND INFANT FORMULA ONLY
UP TO 6 MONTHS OF AGE
6 UP TO 12 MONTHS
12 MONTHS UP TO 2 YEARS
FORMULA FEED
EXCLUSIVELY. Do not give
any breast milk. Other foods or
fluids are not necessary.
GIVE MILK. Give about 1–2
cups (250–500 ml) of infant
formula or boiled (then cooled)
full cream milk. Give milk with a
cup, not a bottle.
COMPLEMENTARY FOODS.
Give adequate servings of
the following foods, or family
foods, 5 times a day:
Prepare correct strength and
amount just before use. Use
milk within two hours. Discard
any left over – a fridge can
store formula for 24 hours.
Cup feeding is safer than bottle
feeding. Clean the cup and
utensils with hot soapy water.
Give the following amounts
of formula up to 6 times per
day:
AGE
(months)
AMOUNT x
TIMES PER DAY
0 up to 1
60 ml x 8
1 up to 2
90 ml x 7
2 up to 3
120 ml x 6
3 up to 4
120 ml x 6
4 up to 5
150 ml x 6
5 up to 6
150 ml x 6
COMPLEMENTARY FOODS.
Start by giving 2–3 tablespoons
of food 2–3 times a day.
Gradually increase to ½ cup
(1 cup = 250 ml) at each meal,
and to 3–4 meals a day.
SNACKS. Offer 1–2 snacks
each day when the child seems
hungry. For snacks give small
chewable items that the child
can hold. Let your child try to
eat the snack.
This should include protein,
and mashed fruits and
vegetables. If possible, give an
additional animal-source food,
such as liver or meat.
These foods can include:
* EXCEPTION: heat-treated
breast milk can be given
53
GIVE MILK. Give about 500 ml
(1–2 cups) or full cream milk or
infant formula per day. Give
milk with a cup. Do not use a
bottle.
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
REVIEWING FEEDING RECOMMENDATIONS CHART
Infant formula
WHAT ARE IMPORTANT REMINDERS ABOUT REPLACEMENT
FEEDING?
When you counsel and caretaker on formula feeding, and provide follow-up care in
subsequent visits, there are important practices to check.
You can ask checking questions about how feeds are being measured, prepared,
and given. Based on what the caregiver explains, you might also ask him/her
to demonstrate for you. Give appropriate feedback. If there are any problems,
demonstrate how to prepare safely and give the feed to the baby.
This is important to check the following:
✔✔ Only replacement feeding is being given, never breastmilk or unsafe fluids
✔✔ Appropriate volume and number of feeds
✔✔ Correct measurement of milk and other ingredients
✔✔ Feeds prepared cleanly and safely (e.g. boiling and cooling milk)
✔✔ Fresh feeds given each time
✔✔ Cup feeds are given for safety
✔✔ Use of hot soapy water for cleaning utensils and cup
REVIEWING FEEDING RECOMMENDATIONS CHART
All HIV-infected or exposed children
WHAT ARE IMPORTANT POINTS ABOUT GIVING CHILDREN FAMILY
FOODS AND SNACKS?
When children begin taking family foods, meals should contain foods that provide
energy such as a staple, but should be combined with other foods to provide enough
of the other essential nutrients such as protein, vitamins and iron.
Good snacks provide both energy and nutrients. Examples of good snacks are:
yoghurt and other milk products; bread or biscuits spread with butter, margarine,
nut paste or honey; fruit; bean cakes; cooked potatoes. Poor value snacks are ones
that are high in sugar but low in nutrients. Examples of these are fizzy drinks (sodas),
sweet fruit drinks, sweets, salty items, and sweet biscuits.
HOW SHOULD FEEDING CHANGE DURING ILLNESS?
Parents and caregivers should increase the amount of fluids they give to children
during illnesses and encourage the child to eat soft, varied, appetizing favourite
foods. After illness, parents and caregivers should give food more often than usual
and encourage the child to eat more. Remember that PERSISTENT DIARRHOEA
has specific feeding recommendations.
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
WHAT ARE SPECIAL FEEDING PROBLEMS HIV-INFECTED CHILDREN
MIGHT HAVE?
HIV-infected children may experience special feeding problems. These may require
further interventions for nutrition or care. In addition to special feeding problems,
HIV-related illnesses like tuberculosis and diarrhoea occur in malnourished
children. They have severe consequences because they can cause appetite loss, weight
loss, and acute malnutrition.
CHILD HAS CLINICAL CONDITIONS THAT AFFECT THEIR NUTRITION
Some clinical conditions may affect the HIV-infected child’s nutrition status. It is
important to identify local nutrient-rich foods that are available and affordable
and to advise the mother on how to increase the energy content of foods. Always
advise the mother to continue feeding and continue giving fluids during any illness.
CLINICAL SITUATION
CONSEQUENCE
WHAT ACTION SHOULD YOU TAKE?
Recurrent or chronic
infection
✔ Increased metabolic
needs
✔ Significantly higher
caloric demands
Offer feeds more frequently than before:
1. The chronic infection should be treated.
2. If the child is breastfeeding breastfeed at least 8 times in 24 hours
3. If the child is on complementary foods, offer small meals at least 5
times a day. Increase the energy value of these feeds by adding oil
or nuts.
4. Follow the recommendations in IMCI chart booklet
Intestinal infections
✔ Increased nutrient
requirements
✔ Impaired absorption
and loss of appetite
may decrease food
intake
✔Diarrhoea
1. These infections should be treated appropriately.
2. Follow the same feeding recommendations for the child with
recurrent or chronic infection
3. Treat for worms if the child has not been treated during the previous
6 months
4. Give Vitamin A if the child has not been treated during the past 6
months
Oral or oesophageal
thrush
✔ Potential pain with
swallowing may result
in decreased oral intake
primarily for solids, but
also for liquids
1. Make sure child receives treatment for thrush
2. Offer foods that have been mashed up or pureed
3. Avoid spicy foods
4. Paracetamol half an hour before feeds may be helpful in extreme
cases
Persistent
diarrhoea caused by
cryptosporidia or other
parasites
✔ Impaired absorption of
nutrients
1. Follow the feeding recommendations for the child with recurrent or
chronic infection (above); the child with intestinal infections (above)
and the child with persistent diarrhoea (in the chart booklet)
Nausea and vomiting
as a result of ARV drugs
1. These are infrequent but may occur.
2. For ritonavir containing medication coat tongue with peanut butter
before dose is given.
3. Encourage small frequent sips of fluids and give food that the child
likes
4. Let the child eat before medication
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
CHILD HAS A POOR APPETITE
This is especially common with HIV infection, and may be made worse if the child
has mouth lesions such as ulcers or oral thrush.
✔✔ Treat the oral lesions urgently and appropriately. Paracetamol may be used in
addition for pain relief before each meal.
✔✔ Use soft, varied favourite foods to encourage the child to eat as much as possible
✔✔ Keep up fluid intake
✔✔ Give foods that are not too thick or dry
✔✔ Offer small, frequent feeds. Feed the child when he is alert and happy. Give more
food if he shows interest.
✔✔ If the child has mouth lesions, offer foods that do not burn the mouth – such
as eggs, mashed potatoes, sweet potato, pumpkin or avocado. Do not give spicy
or salty foods.
✔✔ Ensure that the spoon is the right size, that food is within the reach of the child
and that he is actively fed. For example, he sits on the mother’s lap while eating.
WHAT ARE THE RECOMMENDATIONS FOR SAFELY STOPPING
BREASTFEEDING?
Mothers known to be HIV-infected who decide to stop breastfeeding at any time
should stop gradually within one month. The mother’s reason for stopping should
be discussed and the health worker should assess if there are specific difficulties
that can be overcome. Health workers should discuss with the mother what food
she will give to her infant after stopping breastfeeding and if these will be sufficient
for the child’s growth and development.
HOW SHOULD A MOTHER BE COUNSELLED ABOUT STOPPING
BREASTFEEDING?
It is advised to stop breastfeeding gradually over one month. Below are important
counselling notes.
n Planning ahead: Mothers should think and plan ahead about how she will
provide supplementary foods and alternative sources of milk.
n Comfort is an important part of breastfeeding: babies want to breastfeed
not only because it gives them nutrition but also because they want the comfort
and security of being with their mothers. Stopping breastfeeding means that
mothers need to plan how they will feed their infant and also how they will
comfort them when crying when they are tired or upset. Babies cry when they are
hungry. However, they can also cry when they are tired or want their mother’s
attention. Babies also have growth spurt when they want more milk and therefore
they will want to breastfeed for longer. Mothers sometime interpret crying as
meaning that their baby is always hungry and that they do not have enough
milk. This is not true and the mother should not decide to stop breastfeeding
based on this thinking.
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
n Preparing the baby before breastfeeding is stopped: if a mother plans to
stop breastfeeding then she can help to prepare her baby.
— While breastfeeding, mothers can teach their babies to drink expressed breast
milk from a cup
—If the mother or baby are not receiving ARVs to prevent HIV transmission,
then this milk may be boiled to destroy HIV
—Once the baby is drinking comfortably from a cup, replace one breastfeed
with one cup-feed using expressed breast milk
— Increase the frequency of cup-feeding every few days and reduce the frequency
of breastfeeding. Ask an adult member of the family to help with cup feeding
—Stop putting your baby to your breast completely as soon as your baby is
accustomed to frequent cupfeeding
— If a baby needs to suck, give the child one of your clean fingers instead of the
breast
n Once a mother begins to stop breastfeeding:
—To avoid breast engorgement (swelling) mothers should express a little milk
whenever her breasts feel full. This will help mothers feel more comfortable.
Use cold compresses to reduce inflammation.
—Mothers should not begin breastfeeding again once they have stopped. If
a mother does start again, this may increase the risk of passing HIV to her
baby. If a mother’s breasts become engorged then it is better for her to express
breast milk by hand.
—Mothers should begin using a family planning method of her choice even
before the end of breastfeeding and certainly as soon as she starts reducing
breastfeeds.
— Check with the mother that she has had a blood sample taken for a CD4 count
in the past 6 months and that she knows this result. Remind her that this
should be done every 6 months to assess if she needs lifelong ART for herself.
WHEN SHOULD ARV PROPHYLAXIS BE STOPPED AFTER
BREASTFEEDING STOPS?
Mothers or infants who have been receiving ARV prophylaxis should continue
prophylaxis for one week after breastfeeding is fully stopped. Mothers should also
know to continue the ARV prophylaxis for the child for one week following the complete
cessation of breastfeeding: this means from the date that the child has absolutely
no breastmilk. Health workers must ensure she has enough supplies of ARVs.
WHAT IF A MOTHER IS TOO SICK TO BREASTFEED?
If the HIV-infected mother who has chosen to breastfeed develops symptomatic AIDS,
she may no longer be able to manage the physical requirements of breastfeeding.
Help the mother to make a safe and complete transition to replacement feeds. For
women without adequate financial resources or any family support, you may have
to arrange for a secure supply of formula milk (under six months) or plain milk
(older children).
The mother should be assessed and referred for ART and she should be placed on
cotrimoxazole.
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
WHAT ARE THE FEEDING RECOMMENDATIONS FOR ORPHANS?
Abandoned children or maternal orphans require special consideration. Their
feeding options are as follows:
0 TO 6 MONTHS
Three options for feeding orphans are discussed below:
1. Receive a safe and appropriate breast milk substitute
If the child receives formula milk, make sure that the milk given is appropriate.
Follow the feeding recommendations for a child on formula milk in the Counsel
the mother section of the chart booklet.
2. Receive breast milk from confirmed HIV negative women
If the child receives breast milk from a wet nurse it will be crucial to determine
that this wet nurse is confirmed HIV negative, is not in the window period where
she might still become HIV-infected, and is not at risk of becoming HIV-infected.
3. Receive breast milk from a breast milk bank
If the child receives breast milk from a milk bank, the milk bank should pasteurize
the milk according to standard procedures.
6 to 24 MONTHS
Infants from six months to 2 years who are not breastfed should be given safe family
foods and milk or some other animal-source food every day.
HOW DO YOU COUNSEL A MOTHER ABOUT HER OWN HEALTH?
During a sick child visit, listen for any problems that the mother (or caregiver)
herself may have. The mother may need treatment or referral for her own health
problems. Do not force mothers to queue twice or attend different places for simple
problems. Write down her health concerns at the bottom of the recording form. This
will remind you to help the mother after attending to her child.
WHAT COUNSELLING IS GIVEN TO MOTHERS WHO ARE
HIV-INFECTED?
Mothers known to be HIV-infected should be provided with lifelong antiretroviral
therapy (ART) or antiretroviral prophylaxis interventions to reduce HIV
transmission through breastfeeding according to WHO recommendations. Mothers
should also have blood samples tested every 6 months to measure her CD4 count
and assess if she needs ART.
WHAT ARE IMPORTANT COUNSELLING TOPICS?
✔✔ FAMILY PLANNING – Ask her about family planning and if she is happy with
the method she has chosen. Discuss the alternatives with her and prescribe
contraception as you have been taught in family planning. Offer barrier
contraception as well, and ensure that the mother has enough contraception
for at least 3 months.
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
✔✔ SCREENING FOR SEXUALLY TRANSMITTED INFECTIONS (STI) – Assess
and treat these according to the National STI protocols.
✔✔ SOCIAL PROBLEMS – Encourage the mother to discuss any social problems.
These can include her partner, family, support networks, housing, childcare,
workload, and other issues. Provide ongoing counselling and care if she is HIVinfected. If necessary, refer her.
n Counsel the mother about her own health
✔✔ IF SICK: If the mother is sick provide care for her, or refer her for ART.
✔✔ BREAST PROBLEMS: If she has a breast problem (such as engorgement, sore
nipples, breast infection), provide care or refer her for help.
✔✔ NUTRITION: Advise her to eat well to keep up her own strength and health.
✔✔ TT SHOTS: Check her immunization status and give tetanus toxoid if needed.
✔✔ ACCESS TO HEALTHCARE: Make sure she has access to:
✔✔ Regular testing for CD4 count
✔✔ Contraception and sexual health services
✔✔ Counselling on STI and AIDS prevention
✔✔ STIs: Counsel about safe sex and early treatment of STIs
n Give additional counselling if the mother is HIV-infected
•• FOLLOW UP: Reassure her that with regular follow-up, much can be done to
prevent serious illness, and maintain her and the child’s health
•• HYGIENE & CARE: Emphasize good hygiene, and early treatment of illnesses
•• PAIN: See guidelines for palliative care in chart booklet
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
SELF-ASSESSMENT EXERCISE G – INFANT FEEDING
In this exercise you will answer questions about the feeding recommendations
that you have read about in this module.
1. Are the following statements true or false? These questions are about a country
that recommends breastfeeding and ARV interventions for HIV-infected
mothers.
a. It is advisable to give children fewer feeds during
illness.
TRUEFALSE
b. It is best for a 3-month-old HIV-infected child to be
exclusively breastfed.
TRUE
FALSE
c. It is recommended that a 2-week-old child of
unknown HIV status born to an HIV negative mother
is never breastfed. TRUE
FALSE
d. It is advisable that a breastfeeding child born to an
HIV-infected woman continues breastfeeding for as
long as the mother wants to breastfeed up to
12 months of age.
TRUE
FALSE
e. It is recommended that a 5-month-old child whose
mother is HIV negative breastfeeds as often as he
wants, day and night.
TRUE
FALSE
f. A 9-month-old child who is HIV-infected on
virological (PCR) tests can continue breastfeeding.
TRUE
FALSE
g. All breastfeeding HIV-infected women transmit HIV
to their infants.
TRUE
FALSE
h. It is advisable that a child born to a mother with
unknown HIV status is given formula
TRUE
FALSE
i. ARVs to an HIV-infected mother or to her exposed
infant very significantly reduces the risk of
transmission through breastfeeding
TRUE
FALSE
2. Traci is born to an HIV-positive mother. When should she begin receiving family
foods? What foods should be added, and in what quantity?
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
n How will you advise Lungile about infant feeding?
Lungile is HIV-infected and you have classified Peter as HIV EXPOSED. You must advise Lungile about feeding
options for Peter.
From your IMCI assessment, you know that Peter’s weight is not low for age. You know that Peter is
breastfeeding.
n Peter is 6 months old – what will you recommend his mother?
You will advise Lungile according to the feeding recommendations in your feeding chart:
✔✔ BREASTFEED as often as the infant wants
✔✔ COMPLEMENTARY FOODS. Give 3 adequate servings of nutritious complementary foods, plus one
snack, per day. Each meal should be ¾ cup. 1 cup = 250 ml. This should include protein, and mashed fruits
and vegetables. If possible, give an additional animal-source food, such as liver or meat.
You emphasize that:
•• She should provide safe family foods like porridge and mashed vegetables or fruit. She should give
him 3 meals a day, plus one snack. You ask Lungile about what foods she has available in the home
and what she can afford to give Peter. She tells you that she sometimes has eggs, potatoes, squash,
and some chicken. You tell her how to prepare porridge, and show her how to feed Peter with a
spoon. You ask her checking questions to make sure she understands what you have explained.
•• She should not give Peter sugary drinks or unhealthy snacks.
You will re-evaluate this feeding advice during follow-up visits. You will also discuss breastfeeding
transitions with Lungile at the appropriate time. Remember that once Peter has stopped
breastfeeding for at least 6 weeks, you will test again to confirm his HIV status.
n How will you counsel Lungile about her own health?
You ask more about Lungile’s situation. She tells you that she just found out that she is HIV-infected. Lungile
lives in a tin shack in the centre of the city. She gets water from the tap in the street 200 metres from her
home. She lives alone. Her partner works in another city and comes home at weekends. Her mother lives on
the farm. Lungile visits her mother during Christmas.
Previously she was working temporary jobs. Since Peter was born, she has struggled trying to find work
during the days. She thinks that she might take Peter to the farm for some time. When she returns to the
city her mother will look after her baby. Neither her mother nor her partner knows that she is HIV infected.
She wants to tell her partner but she is scared. Maybe he will get angry with her and he will not give her any
money for Peter’s care.
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
n What are important topics to discuss with Lungile?
Lungile has a complicated social situation. Today you want to discuss the most important care topics, and
encourage Lungile to continue seeking counseling and HIV care.
Lungile might already be receiving counseling on these topics at her clinic. Today you can ask her more
about the care she is receiving. If you notice areas that should be discussed more, you can address these with
her.
Lungile will need to be counseled on:
✔✔ HEALTH: is she ill?
✔✔ ACCESS TO CARE and FOLLOW UP: how frequently is she going for visits at the clinic where she was
tested for HIV and is receiving care?
✔✔ FEEDING PROBLEMS: including breast problems?
✔✔ IMMUNIZATIONS: does she have her TT shots?
✔✔ NUTRITION: what advise has she been given about eating well? She must keep up her own health and
strength, this is critical.
✔✔ SEXUALLY TRANSMITTED INFECTIONS: does she have any signs?
✔✔ FAMILY PLANNING: what method is she using, and is she happy with it?
✔✔ HYGIENE: discuss handwashing and other important hygiene practices, especially keeping Peter in mind
Lungile does not feel ill today, but has many questions for you about her own nutrition. She is also worried
that she is not making enough milk for Peter, so you discuss this issue. Her other clinic has provided her
immunizations, screening for sexually transmitted infections, and a family planning method (condoms), so
you only briefly discuss these topics.
Now you will return to Peter’s care. This counseling with Lungile has given you a better sense for Peter’s
environment and how the two of them will seek care. This information will be useful for approaching
treatment. You will now learn about treatment for Peter.
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
8.8
ANTIRETROVIRAL TREATMENT
What are the learning objectives for this section?
After you study this section, you will know how to:
•• Describe the common antiretroviral drugs
•• Decide which children are eligible to receive ART
•• Stage children using the clinical staging criteria in the IMCI chart booklet
•• Understand which children should be started on ART by nurses at primary
level
•• Refer certain children to a doctor for initiation of ART
•• Undertake a baseline assessment, including sending of laboratory results
•• Counsel the mother/care giver for adherence to ART
•• Describe the recommended ARV regimens for children
•• Prescribe ARVs in the correct dosages
•• Explain the possible side effects of ARV drugs and know how to manage them
SECTION OUTLINE
This section is separated into three parts. These are described below:
1. WHAT IS ANTIRETROVIRAL TREATMENT?
2. THE FIVE STEPS OF INITIATING ART IN CHILDREN
1st. Decide if child has confirmed HIV infection
2nd.Decide if caretaker is able to give ART
3rd. Decide if ART can be initiated in your first level facility
4th.Record baseline information on the child’s HIV treatment card
5th.Start on ART and cotrimoxazole prophylaxis
3. SIDE EFFECTS OF ARVS
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
PART 1: What is antiretroviral treatment?
HIV is a special kind of virus called a retrovirus. So the drugs against HIV are called
antiretroviral drugs:
Anti
Retro
shortened to ARV drugs, or simply ARVs
Viral drugs
In the first part of this module, you learned about how the HIV virus replicates by
turning CD4 cells into HIV ‘factories’. Antiretroviral drugs interfere with the life
cycle of the HIV virus, thus preventing it from replicating.
Giving ARVs in the correct way, with adherence support, is called ARV Therapy. This
is shortened to ART. ART does NOT cure HIV, but through preventing replication
of the virus it prevents immune system damage and can improve the quality of life
and life expectancy of the patient.
HOW IS ART DIFFERENT FOR CHILDREN AND ADULTS?
Antiretroviral (ARV) drugs are handled differently in children’s bodies, affecting
the doses that are needed. Dosages in children need to be adjusted to weight as the
child grows.
WHICH CHILDREN ARE GIVEN ANTIRETROVIRAL DRUGS?
All children under five who are CONFIRMED HIV INFECTION are eligible to receive
ART.
WHY ARE SEVERAL ARVS GIVEN AS ONE TREATMENT?
For ART to be effective it is important that a combination of three drugs is used,
rather than using one or two drugs. Combination therapy for HIV is like combination
therapy for TB, and makes sense for lots of reasons. Here are the most important
ones:
n IT TAKES A LOT OF FORCE TO STOP HIV
HIV makes new copies of itself very rapidly. Every day, many new copies of HIV
are made. Every day, many infected cells die. One drug, by itself, can slow down
this fast rate of infection of cells. Two drugs can slow it down more, and
three drugs together have a very powerful effect.
n ARVs from different drug groups attack the virus in different ways
Different ARV drugs attack HIV at different steps of the process of making copies
of itself: first when entering the cell, second when making new copies and third
when the new copies want to leave the cell. Targeting at least two of these
steps increases the chance of stopping HIV from making new copies of
itself and preventing new immune cells from infection.
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
n Combinations of anti-HIV drugs may overcome or delay resistance
Resistance is the ability of HIV to change its structure in ways that make drugs
less effective. HIV has to make only a single, small change to resist the effects
of some drugs such as nevirapine.
For other drugs, such as zidovudine, HIV has to make several changes. When
one drug is given by itself, sooner or later HIV makes the necessary changes to
resist that drug. But if two drugs are given together, it takes longer for
HIV to make the changes necessary for resistance. When three drugs
are given together, it takes even longer.
WHAT ARE COMMONLY USED ANTIRETROVIRAL DRUGS?
ARV classes and examples of ARVs are shown in the table below. You will learn much
more about these ARVs later in this module. Recommended first-line regimens
usually include 2 NsRTI with 1 NNRTI.
STAVUDINE: You should note that stavudine was previously used as a first-line
agent, and many children are still on this drug. However it is no longer a preferred
first-line treatment.
Nucleoside reverse
transcriptase
inhibitors (NsRTI)
Nucleotide reverse
transcriptase
inhibitors (NtRTI)
Non-nucleoside
reverse
transcriptase
inhibitors (NNRTI)
Protease inhibitors
(PI)
lamivudine (3TC)
stavudine (d4T)
zidovudine (AZT)
didanosine (ddI)
abacavir (ABC)
tenofovir disoproxil
fumarate (TDF)
nevirapine (NVP)
efavirenz (EFV)
lopinavir (LPV)
indinavir (IDV)
retonavir (RTV)*
atazanavir (ATV)
darunavir
* ritonavir is used as a ‘helper’ for one PI to make the effect of a second PI stronger
WHEN IS IT POSSIBLE TO INITIATE ART?
Before starting antiretroviral therapy, a child must first be stabilised. This means
any acute common illnesses and opportunistic infections must be treated and the
general condition of the child improved. The following pages discuss the 6 steps for
initiating ART in children.
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
PART 2: HOW DO YOU INITIATE ART IN CHILDREN?1
There are 5 steps to initiating ART in children. These are also in your chart booklet.
You will read more about each step in the following pages. Remember that if a
child has any general danger sign or a severe classification, they need URGENT
REFERRAL. ART initiation is not urgent, but should be initiated as soon as the
5 steps are completed.
STEP 1: DECIDE IF THE CHILD HAS CONFIRMED HIV
INFECTION
STEP 3: DECIDE IF ART CAN BE INITIATED IN YOUR FIRST
LEVEL FACILITY
Child is under 18 months:
n HIV infection is confirmed if virological (PCR) is positive
n Check that child has not breastfed for at least 6 weeks
➜ If child weighs less than 3 kg or has TB, refer for ART
initiation.
➜ If child weighs 3 kg or more and does not have TB,
move to STEP 4
Child is over 18 months:
n Two different serological tests are positive
n Send any further confirmatory tests required
n If results are discordant, refer
➜ If HIV infection confirmed, and child is stable, move to
STEP 2
STEP 2: DECIDE IF CAREGIVER IS ABLE TO GIVE ART
STEP 4: RECORD BASELINE INFORMATION ON THE
CHILD’S HIV TREATMENT CARD
Check that the caregiver is willing and able to give ART. The
caregiver should ideally have disclosed the child’s HIV status
to another adult who can assist with providing ART, or be
part of a support group.
➜ If caregiver able to give ART: move to STEP 3
➜ If caregiver not able: classify as CONFIRMED HIV
INFECTION not on ART. Follow-up regularly. Support
caregiver and move forward once she is willing and able
to give ART.
Record the following information:
n Weight and height
n If pallor is present
n If child has feeding problem
n Laboratory results (if available): Hb, viral load, CD4 count
and percentage
➜ Send any laboratory tests that are required. If the child is
confirmed HIV infection, do not wait for results.
➜ Move to STEP 5
STEP 5: START ON ART TREATMENT AND COTRIMOXAZOLE PROPHYLAXIS
n Child is up to 3 years old: initiate preferred ART treatment: ABC or AZT +3TC+ LPV/R or other recommended first-line
regimen
n Child is 3 years or older but less than 35 kg: initiate preferred ART treatment: ABC + 3TC + EFV, or other recommended
first-line regimen
n Give cotrimoxazole prophylaxis
n Give other routine treatments, including Vitamin A and immunizations
n Follow-up regularly as per national guidelines
1
These steps were modified from South Africa’s IMCI Chart Booklet (2011).
66
Child 18 months and over:
 YES  NO
 Virological test positive
Ensure child has not breastfed for
at least 6 weeks
 Serological test positive
 Second serological test positive
Ensure child has not breastfed for
at least 6 weeks
67
 YES
 NO
PROVIDE FOLLOW-UP CARE
STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS
• Child is under 3 years old: Initiate preferred first-line regimen
• Child is 3 years or older: Initiate preferred first-line regimen
• Cotrimoxazole
• Give other routine treatments, including Vitamin A and immunizations
STEP 4: ASSESS AND RECORD BASELINE INFORMATION
• Record weight and height,
 SEVERE ACUTE MALNUTRITION
assess & classify malnutrition
 MODERATE ACUTE MALNUTRITION
 NO ACUTE MALNUTRITION
• Pallor is present
 YES  NO
• Child has feeding problem
 YES  NO
• Hb: ............................. g/dl
Viral load: ....................................................
• CD4 count: ......................... cells/mm3 CD4 percentage ......................... %
• WHO clinical stage today: ................................................................................................
STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR
FIRST LEVEL FACILITY
• Weight under 3 kg
 YES  NO
• Child has TB
 YES  NO
STEP 2: CAREGIVER ABLE TO GIVE ART
 YES  NO
 YES: caregiver available and willing to give medication
 YES: caregiver has disclosed to another adult, or is part of a support group
•
STEP 1: CONFIRM HIV INFECTION
• Child under 18 months:
ASSESS
Weight: ............ kg
REFER IF:
— COMPLICATED SEVERE ACUTE MALNUTRITION
— SEVERE OR SOME ANAEMIA
If none present: GO TO STEP 5
•
•
•
•
Follow-up after one week
If child is stable, follow-up regularly
RECORD OTHER TREATMENTS HERE:
RECORD ARVS & DOSAGES HERE:
1. .............................................................................................................
2. .............................................................................................................
3. .............................................................................................................
Send tests that are required
If any present: REFER NON-URGENTLY
If none present: GO TO STEP 4
If NO: classify as CONFIRMED HIV INFECTION NOT ON ART
If none present: GO TO STEP 3
Send any test required, including confirmation test
If HIV infection confirmed, and child is in stable
condition, GO TO STEP 2
Age: ......................
•
•
•
•
•
•
•
TREAT
STARTING ART: FOLLOW THE FIVE STEPS Name: .............................................................................
Date: ....................
NEXT FOLLOW-UP DATE: ..................................................
RECORD ACTIONS AND TREATMENTS HERE:
ALWAYS REMEMBER TO COUNSEL THE MOTHER AND
PROVIDE ROUTINE CARE
Temperature: ............... °C
In addition to the IMCI recording form, you will use a supplementary form to record the five steps and your assessments. It includes critical instructions
for each step, and is a very useful job tool when determining HIV/AIDS care using IMCI. Review the form below:
RECORDING THE FIVE STEPS:
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
STEP 1. CONFIRM HIV INFECTION
The first step in initiating ART is to confirm the diagnosis of HIV infection. In
many cases, all the necessary tests will have been done, and you must correctly
document the results. In other cases it may be necessary to do some of the tests,
and to record the results.
HOW DO YOU CONFIRM HIV INFECTION IN CHILDREN LESS
THAN 18 MONTHS?
A positive virological (PCR) test is required to confirm HIV infection in children
less than 18 months of age.
HOW DO YOU CONFIRM HIV INFECTION IN CHILDREN 18 MONTHS
OR OLDER?
HIV infection in children older than 18 months of age is diagnosed using a serological
test. If the first serological test is positive, it requires a confirmatory test. If the
child is 18 months or older, repeat a serological test.
WHAT ARE YOUR NEXT STEPS AFTER A CHILD IS CONFIRMED
INFECTED?
Before starting antiretroviral therapy, a child must first be stabilised. This means
any acute common illnesses and opportunistic infections must be treated and the
general condition of the child improved. If the child is stable, you will then move
on to STEP 2.
REVIEW: WHAT PART OF THE ART INITIATION FORM IS USED FOR
STEP 1?
Review this section of the recording form to become familiar with the information
STARTING ART:
FOLLOW THE FIVE STEPS Name: .............................................................................
recorded:
ASSESS
Age: ......................
Weight: ............ kg
TREAT
 YES  NO
 Virological test positive
Ensure child has not breastfed for
at least 6 weeks
 Serological test positive
 Second serological test positive
Ensure child has not breastfed for
at least 6 weeks
•
•
Send any test required, including confirmation test
If HIV infection confirmed, and child is in stable
condition, GO TO STEP 2
STEP 2: CAREGIVER ABLE TO GIVE ART
 YES  NO
 YES: caregiver available and willing to give medication
 YES: caregiver has disclosed to another adult, or is part of a support group
•
•
If NO: classify as CONFIRMED HIV INFECTION NOT ON ART
If none present: GO TO STEP 3
•
•
If any present: REFER NON-URGENTLY
If none present: GO TO STEP 4
STEP 4: ASSESS AND RECORD BASELINE INFORMATION
• Record weight and height,
 SEVERE ACUTE MALNUTRITION
assess & classify malnutrition
 MODERATE ACUTE MALNUTRITION
 NO ACUTE MALNUTRITION
• Pallor is present
 YES  NO
• Child has feeding problem
 YES  NO
• Hb: ............................. g/dl
Viral load: ....................................................
• CD4 count: ......................... cells/mm3 CD4 percentage ......................... %
• WHO clinical stage today: ................................................................................................
•
Send tests that are required
•
REFER IF:
— COMPLICATED SEVERE ACUTE MALNUTRITION
— SEVERE OR SOME ANAEMIA
•
If none present: GO TO STEP 5
STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS
• Child is under 3 years old: Initiate preferred first-line regimen
RECORD ARVS & DOSAGES HERE:
1. .............................................................................................................
STEP 1: CONFIRM HIV INFECTION
• Child under 18 months:
•
Child 18 months and over:
Temperature: ..
STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR
FIRST LEVEL FACILITY
• Weight under 3 kg
 YES  NO
• Child has TB
 YES  NO
 YES
 NO
68
RECORD ACTIO
ALWAYS REMEM
PROVIDE ROUTI
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
SELF-ASSESSMENT EXERCISE H – CONFIRMING HIV INFECTION
1. Why is it important to use 3 drugs in ART for children?
2. Decide whether or not these children have confirmed HIV infection. The answer
may be: YES, NO, or TO BE CONFIRMED. If the answer is TO BE CONFIRMED,
write down in the final column what needs to done to confirm whether or not
the child has HIV infection.
Does the child have HIV infection?
a. 2 month old child has a positive
PCR test.
b. 12 month old child with positive
PCR test.
c. A 2 month old breastfeeding
child has a positive HIV
serological test.
d. An 18 month old breastfeeding
child has a positive HIV serological
test. A second test is also positive.
e. 9 month old breastfeeding child
has a negative PCR test. Mother
is HIV infected. f. An 19 month old has a positive
serological test. The second test
is negative.
g. 9 month old child has a negative
PCR test. The child last breastfeed
3 months ago.
h. An 18 months old child has a
negative serological test. The child
last breastfed one week ago.
69
What should be done to
confirm the diagnosis?
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
SELF-ASSESSMENT EXERCISE I – ART ELIGIBILITY
Decide whether or not the following children are eligible to receive ART.
AGE
DETAILS
ANSWER
a. 4 years
Child is CONFIRMED HIV INFECTION but
appears healthy
b. 6 months
Child is HIV exposed, and mother is very sick
c. 9 months
Child had a positive serological test
d. 3 years
Child had a positive serological test
e. 9 years
Child is CONFIRMED HIV INFECTION
STEP 2. MAKE SURE THAT THE CARETAKER IS READY
TO GIVE ART
Adherence is the cornerstone of successful ART. For a good response at least
95% of the ARVs need to be taken.
WHAT MAKES ADHERENCE COMPLICATED FOR CHILDREN?
Adherence is therefore the key to successful therapy, but may be difficult to achieve
in children due to a number of reasons:
■■ Young children are heavily reliant on their parents/caregivers to
ensure adherence. There may be a poor understanding of the need to take the
medication both for parent and the child.
■■ Many parents may not wish to disclose the HIV status to the child or to
others involved in care.
■■ Lack of suitable easy to use paediatric fixed dose combinations means
complicated mixtures of pills/syrups need to be taken.
■■ Often the medicines are often not palatable to children, resulting in
difficulty in their administration.
WHAT SOCIAL ENVIRONMENTS ARE IMPORTANT FOR ADHERENCE?
The social criteria attempt to ensure good adherence. They aim to ensure that
adherence is at least probable. They are:
■■ Availability of at least one identifiable caregiver who is able to supervise
the child for administering medication (all efforts should be made to ensure that
the social circumstances of vulnerable children, e.g. orphans, are addressed so
that they too can receive treatment)
■■ Disclosure to another adult living in the same house is encouraged so that
there is someone else who can assist with the child’s ART
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
WHY SHOULD THESE CRITERIA BE MET BEFORE INITIATING ART?
The social criteria highlight the fact that starting ART is not just a medical
issue, but has implications for the child and his/her caregiver. These criteria
should not be used as a barrier to giving a child ART, but should rather be thought
of as part of the process for preparing a child to start ART.
Some caregivers may be ready to commit themselves to giving their child ART
immediately, while others may need more time to get used to the idea. In some
instances there may be practical problems or issues that need to be addressed.
HOW CAN HEALTH WORKERS PREPARE CARETAKERS AND
CHILDREN FOR ADHERENCE?
Health care providers should use the ‘5 As’ to prepare children and their caregivers
for ART adherence. These are helpful to use during each clinic or follow-up visit.
‘5 As’ for adherence counselling
1. ASSESS 2. ADVISE 3. AGREE 4. ASSIST 5. ARRANGE
1. ASSESS
Try to ensure that a treatment supporter is identified. Make sure that the
caregiver understands that ART is lifelong therapy, and that she understands the
side effects of the medication. Though one cannot force another to disclose, the
primary caregiver should be supported to identify an additional person who can
assist treatment supervision. This will also provide insight into potential family
supports and challenges to successful chronic care adherence.
2. ADVISE
As you have learned in the previous counselling lessons in IMCI, it is very important
when advising caretakers to approach them in an open, non-judgmental, and patient
way. You might introduce the topic like this: “I have some information about HIV and
AIDS and ART. Would you like to hear it?”
Do not overwhelm the caregiver with too much information at once. She
will need time to think about and digest some information before being able to
concentrate on further information. That is why it is good to split the advice over
several visits, and indicate on the education side of the child’s treatment card the
information that has been given already.
WHAT TOPICS SHOULD HEALTH WORKERS ADVISE
CARETAKERS ON?
HIV ILLNESS AND EXPECTED PROGRESSION: Explain that in children the
progression of disease is often rapid. Children may be asymptomatic, but will
become vulnerable to opportunistic infections that gradually become more serious.
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
ARV THERAPY (ART): Advise the caregiver that ARVs are life-saving drugs. Her
child’s life depends on taking the correct dose twice daily and at the right time.
ADVISE ON WHAT ADDITIONAL STEPS SHOULD BE TAKEN TO IMPROVE
ADHERENCE
•• Involve all caregivers, both parents, and child (depending on age and
maturity) in counselling sessions. Careful disclosure to the child can help
them understand why adherence is important. In many cases the child will be
too young to understand. It is important to gradually disclose to the child. This
is the caregiver’s responsibility, but the health worker or counsellor needs to
support and facilitate the process of disclosure.
•• Involve school nurses or orphanage staff, if and where applicable
•• Consider referral to support groups if available
3. AGREE
It is important to establish that the caregiver (and the child in older children) is
willing and motivated, and agrees to treatment, before initiating ART. The caregiver
must be willing to take responsibility for regular supervision of treatment and make
any life adjustments this may require. As children get older it is important they
know about ART and understand the importance of 100% adherence.
Start by asking: “After hearing all the explanation and advice, how do you think your
child will be able to take this kind of treatment?”
HOW CAN YOU CHECK THE MOTIVATION OF THE CAREGIVER?
In addition to considering the response to this question, use some other measures
to check the motivation of the caregiver (since in practice the health care provider’s
impression does not always correspond with the real situation).
You can check, for example:
•• Has the caregiver demonstrated ability to keep appointments for her child and
to adhere to other medications?
•• Does the caregiver want treatment for her child and understand what treatment is for?
•• Is the caregiver willing to bring
the child to the clinic for the
required follow-up?
•• Is the caregiver taking her treatment or does she need it?
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
4. ASSIST
Explore what is needed to assist the caregiver with ART for her child:
“What problems might arise when you follow this plan?”
“What questions do you have about this treatment or how to follow this plan?”
WHAT KINDS OF ASSISTANCE WILL A CAREGIVER NEED FOR
PROVIDING ART?
Help the caregiver develop the resources/support/arrangements needed for
adherence. These include:
•• Ability to bring the child for required schedule of follow-up – plans for time off
work and transport need to be in place.
•• Home and work situation of caregiver that permits her giving medications
regularly to the child without stigma
•• Supportive family or friends
•• Disclosure to child and or family
•• ART adherence support group
5. ASSIST
Note that it is often not be possible to prepare the caregiver and child for adherence
on the same visit that you decide the child is medically eligible for ART. It usually
takes at least 2 to 3 visits and the involvement of others on the clinical team and
a treatment supporter.
The adoption of ART requires long-term commitment on the side of both
the clinical team and the caregiver (and child, depending on his/her age).
Both will need support and help from treatment supporters and others in
the community.
If the caregiver needs another adherence preparation session, arrange a follow-up
to reinforce key messages. Arrange an appointment with the ART support group if
the caregiver wishes so. Remember that it is important to provide ongoing support
and counselling to an HIV-infected caregiver. Refer to a support group with other
caregivers
It often takes 2 to 3 visits to prepare a caregiver and child for adherence,
involve others on the clinical team, and arrange treatment supporters.
73
STARTING ART: FOLLOW THE FIVE STEPS Name: .............................................................................
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
ASSESS
Age: ......................
Weight: ..
TREAT
 YES  NO
• Send any test required, including confirmation
 Virological test positive
• If HIV infection confirmed, and child is in st
Ensure child has not breastfed for
condition, GO TO STEP 2
at least 6 weeks
• Child 18
and over: form to
 become
Serological familiar
test positivewith the information
Review this section
ofmonths
the recording
 Second serological test positive
being recorded.
Ensure child has not breastfed for
at least 6 weeks
STEP 1: CONFIRM HIV INFECTION
• Child under 18 months:
REVIEW: WHAT PART OF THE ART INITIATION FORM
IS USED FOR STEP 2?
STEP 2: CAREGIVER ABLE TO GIVE ART
 YES  NO
 YES: caregiver available and willing to give medication
 YES: caregiver has disclosed to another adult, or is part of a support group
STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR
FIRST LEVEL FACILITY
• Weight under 3 kg
 YES  NO
• Child has TB
 YES  NO
 YES
 NO
•
•
If NO: classify as CONFIRMED HIV INFECTION N
If none present: GO TO STEP 3
•
•
If any present: REFER NON-URGENTLY
If none present: GO TO STEP 4
STEP 3. DECIDE IF ART CAN BE INITIATED AT YOUR
FIRST-LEVEL
FACILITY
STEP 4: ASSESS
AND RECORD BASELINE INFORMATION
• Send tests that are required
 SEVERE ACUTE MALNUTRITION
 MODERATE
ACUTE
• REFER
IF:
Once a
taken,
it needs
to MALNUTRITION
be decided WHERE
and
 NO ACUTE MALNUTRITION
— COMPLICATED SEVERE ACUTE MALNUTRIT
WHO will initiate
the ART. This can be a nurse
or a doctor. Your national guidelines
• Pallor is present
 YES  NO
— SEVERE OR SOME ANAEMIA
will specify WHERE
and
WHO
can
initiate
ART.
• Child has feeding problem
 YES  NO
• Hb: ............................. g/dl
Viral load: ....................................................
• If none present: GO TO STEP 5
• CD4 count: ......................... cells/mm3 CD4 percentage ......................... %
• WHO clinical stage today: ................................................................................................
•
Record weight and height,
& classify
malnutrition
decisionassess
to start
ART
has been
WHEN CAN ART BE INITIATED IN A FIRST-LEVEL FACILITY?
STEP doctors
5: START ART
TREAT AND
COTRIMOXAZOLE
PROPHYLAXIS
RECORD
In the past, only
initiated
ART,
but it is anticipated
that nurses will
play ARVS
an & DOSAGES HERE:
• Child is under 3 years old: Initiate preferred first-line regimen
1. ......................................................................................
increasing role. In general, nurses should initiate ART in children who are stable.
• Child is 3 years or older: Initiate preferred first-line regimen
2. ......................................................................................
This means they
are not ill and do not have signs of advanced HIV infection.
• Cotrimoxazole
3. ......................................................................................
•
Give other routine treatments, including Vitamin A and immunizations
WHEN DO CHILDREN REQUIRE REFERRAL FOR ART?
RECORD OTHER TREATMENTS HERE:
In general, the following children should be referred to a doctor for initiation of
•
Follow-up after one week
PROVIDE FOLLOW-UP CARE
ART, or a nurse
should start ART in consultation with a doctor.
•
If child is stable, follow-up regularly
1. Children who weigh less than 3 kg
Initiating ART is difficult in very small children due to the small doses that are
required. These children should be referred to the next level of care for initiation
of ART.
2. Children with TB or children in whom TB is suspected
It can be difficult to diagnose TB in children with HIV infection, and investigations
such as Chest X-rays and sputum microscopy, are required. ART doses also need
to be adjusted. These children require referral.
WHAT DOES NON-URGENT REFERRAL MEAN IN THIS CONTEXT?
Non-urgent referral will mean different things in different settings. Children
should be referred as soon as possible, but it does not need to be the same day. The
children should be referred to an on-site doctor if available, or to the local hospital
or community health centre. Many children who should be started on treatment
by doctors, can be referred to nurses for follow-up and ongoing care.
Remember that if the child has a general danger sign or a severe
classification, they must be referred urgently.
74
STARTING ART: FOLLOW THE FIVE STEPS Name: .............................................................................
ASSESS
Age: ......................
Weight: ............ kg
Tempe
TREAT
STEP 1: CONFIRM HIV INFECTION
 YES  NO
• Send any test required, including confirmation test
IMCI DISTANCE LEARNING COURSE
| MODULE 8.
HIV/AIDS
• Child under 18 months:
 Virological test positive
• If HIV infection confirmed, and child is in stable
Ensure child has not breastfed for
condition, GO TO STEP 2
at least 6 weeks
• Child 18 months and over:
 Serological test positive
 Second serological test positive
Ensure child has not breastfed for
at least 6 weeks
RECOR
ALWAY
PROVID
REVIEW: WHAT PART OF THE ART INITIATION FORM
IS USED FOR STEP 3?
Review this section of the recording form to become familiar with the information
STEP 2: CAREGIVER ABLE TO GIVE ART
 YES  NO
being recorded.
 YES: caregiver available and willing to give medication
 YES: caregiver has disclosed to another adult, or is part of a support group
STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR
FIRST LEVEL FACILITY
• Weight under 3 kg
 YES  NO
• Child has TB
 YES  NO
 YES
 NO
•
•
If NO: classify as CONFIRMED HIV INFECTION NOT ON ART
If none present: GO TO STEP 3
•
•
If any present: REFER NON-URGENTLY
If none present: GO TO STEP 4
STEP 4: ASSESS AND RECORD BASELINE INFORMATION
• Send tests that are required
• Record weight and height,
 SEVERE ACUTE MALNUTRITION
assess & classify malnutrition
 MODERATE ACUTE MALNUTRITION
• REFER IF:
 NO ACUTE MALNUTRITION
— COMPLICATED SEVERE ACUTE MALNUTRITION
• Pallor is present
 YES  NO
— SEVERE OR SOME ANAEMIA
• Child has feeding problem
 YES  NO
• Hb: ............................. g/dl
Viral load: ....................................................
• If none present: GO TO STEP 5
Children
who arecells/mm
started
on
should
begin to%thrive. It is important that baseline
3
CD4ART
percentage
.........................
• CD4
count: .........................
• WHO
clinical stage today:
................................................................................................
information
is recorded
before they begin ART. This same baseline information will
STEP 4. RECORD BASELINE INFORMATION
WHY IS BASELINE INFORMATION IMPORTANT?
STEP 5:
ART TREATduring
AND COTRIMOXAZOLE
PROPHYLAXIS
beSTART
monitored
the course of
their ART. This
• Child is under 3 years old: Initiate preferred first-line regimen
be monitored.
• Child is 3 years or older: Initiate preferred first-line regimen
• Cotrimoxazole
• Give other routine treatments, including Vitamin A and immunizations
ARVS & DOSAGES
HERE:
way, RECORD
their response
to ART
can
1. .............................................................................................................
2. .............................................................................................................
3. .............................................................................................................
WHAT BASELINE INFORMATION IS DOCUMENTED?
RECORD OTHER TREATMENTS HERE:
The following information should be clearly documented:
PROVIDE
FOLLOW-UP
CARE
IMCI
NUTRITIONAL
•
•
CLASSIFICATION
Follow-up after one week
If child is stable, follow-up regularly
Assess and classify the child’s nutritional status using the relevant chart in the
IMCI chart booklet. If the child has a severe classification they must be referred.
All other children should be managed according to IMCI TREAT charts. ART should
not be delayed.
FEEDING ASSESSMENT
Use the guidance in your chart booklet to assess the feeding of:
•• All children under 2 years of age
•• Children classified with acute malnutrition
•• Check for feeding problems of all young infants
Counsel the mother regarding feeding recommendations and any feeding problems.
CLINICAL STAGING
If the child has not already been staged, do this now as described above. Make
sure that you record the child’s stage from 1 to 4. Information about staging is
located in Annex 1.
CD4 COUNT AND PERCENTAGE
CD4 should be measured at the time of diagnosing HIV infection, prior to starting
ART (as possible, and preferably with increasing frequency as the CD4 count
approaches the threshold for starting ART), and every 6 months once the child
has initiated ART. Send these tests if they have been done or were done more than
three months ago. Record them accurately.
75
NEXT F
ASSESS
TREAT
STEP 1: CONFIRM HIV INFECTION
• Child under 18 months:
•
 YES
 NO
•
Send any test required, including confirmation test
Virological test positive
• If HIV infection confirmed, and child is in stable
IMCI DISTANCE
LEARNING COURSE | MODULE
8. HIV/AIDS
Ensure child has not breastfed for
at least 6 weeks
Child 18 months and over:
 Serological test positive
 Second serological test positive
VIRAL LOAD MONITORING
Ensure child has not breastfed for
at least 6 weeks
Viral load testing is desirable,
but not essential.
condition, GO TO STEP 2
RECORD AC
ALWAYS REM
PROVIDE RO
It is not always available.
STEP 2: CAREGIVER ABLE TO GIVE ART
 YES  NO
 YES: caregiver available and willing to give medication
 YES: caregiver has disclosed to another adult, or is part of a support group
•
•
If NO: classify as CONFIRMED HIV INFECTION NOT ON ART
If none present: GO TO STEP 3
REVIEW: WHAT PART OF THE ART INITIATION FORM
IS USED
FOR
STEP 4?
STEP 3: DECIDE
IF ART CAN
BE INITIATED
AT YOUR
 YES  NO
• If any present: REFER NON-URGENTLY
FIRST LEVEL
FACILITYthis section of the recording form to become •familiar
If none present:
GO information.
TO STEP 4
Review
with the
• Weight under 3 kg
 YES  NO
• Child has TB
 YES  NO
STEP 4: ASSESS AND RECORD BASELINE INFORMATION
• Record weight and height,
 SEVERE ACUTE MALNUTRITION
assess & classify malnutrition
 MODERATE ACUTE MALNUTRITION
 NO ACUTE MALNUTRITION
• Pallor is present
 YES  NO
• Child has feeding problem
 YES  NO
• Hb: ............................. g/dl
Viral load: ....................................................
• CD4 count: ......................... cells/mm3 CD4 percentage ......................... %
• WHO clinical stage today: ................................................................................................
STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS
• Child is under 3 years old: Initiate preferred first-line regimen
• Child is 3 years or older: Initiate preferred first-line regimen
• Cotrimoxazole
• Give other routine treatments, including Vitamin A and immunizations
•
Send tests that are required
•
REFER IF:
— COMPLICATED SEVERE ACUTE MALNUTRITION
— SEVERE OR SOME ANAEMIA
•
If none present: GO TO STEP 5
RECORD ARVS & DOSAGES HERE:
1. .............................................................................................................
2. .............................................................................................................
3. .............................................................................................................
STEP 5. START ART AND COTRIMOXAZOLE PROPHYLAXIS
RECORD OTHER TREATMENTS HERE:
WHEN SHOULD CHILD CONFIRMED WITH HIV
INFECTION
BEGIN ART?
•
PROVIDE FOLLOW-UP
CARE
All children
Follow-up after one week
under 5 years of age with confirmed
infection
should
begin
• HIV
If child
is stable, follow-up
regularly
ART. This is a new and important recommendation for paediatric HIV.
If children are 5 years and older, there are two criteria used to determine
eligibility for ART:
✔✔ CD4 count less than 500 cells/mm3 (give priority to those with CD4 less than
350), or
✔✔ Clinical stage 3 or 4
All HIV-infected children under 5 should begin ART
WHAT FORMS ARE ARVS AVAILABLE IN?
Most ARVs are currently available separately. However it is anticipated that fixed
dose combinations and co-packaged formulations will become available. This will
facilitate dispensing of ARVs, and promote adherence by reducing the number of
medicines that patients have to take.
HOW WILL YOU DETERMINE ARV DOSING?
Doses are based on the child’s weight. It is important to regularly check that
children receive the correct dose based on their weight as they grow. Switch
to tablets or capsules from syrups or solutions as soon as possible. Ensure the
caregiver demonstrates ability to properly use a dosing syringe when prescribing
liquid preparations. In older children or adolescents ensure that maximum doses
are not exceeded.
76
NEXT FOLLO
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
WHAT ARE FIRST-LINE ARV RECOMMENDATIONS
FOR AGE BELOW 3 YEARS?
The following regimens are recommended by WHO as first line ART for children
age below 3 years. The choice of ART regimen at country level will be determined
by national guidelines.
AGE
Birth up to
3 years
PREFERRED
ALTERNATIVE
CHILDREN WITH TB/HIV INFECTION
ABCa or AZT + 3TC + LPV/rb
ABC or AZT + 3TC + NVP
ABC or AZT + 3TC + NVP
AZT + 3TC + ABC
Special notes:
a
Based on the general principle of using non-thymidine analogues in first-line and thymidine analogues in second-line regimens, ABC should
be considered as the preferred NRTI whenever possible. This recommendation was developed by the CHAIN working group. Availability and
cost should be carefully considered.
b
As recommended by the Food and Drug Administration (FDA), the use of LPV/r oral liquid should be avoided in premature babies (born one
month or more before expected date of delivery) until 14 days after their due date, or in full-term babies younger than 14 days of age. Dosing
in children younger than 6 weeks should be calculated based on body surface area (see Annex 3).
WHAT ARE FIRST-LINE ARV RECOMMENDATIONS FOR AGE 3 YEARS
AND ABOVE?
The following regimens are recommended by WHO as first line ART for children
3 years and above. The choice of ART regimen at country level will be determined
by national guidelines. After the age of 3 years the child could be switched to an
EFV-based regimen.
AGE
3 years and older
PREFERRED
ALTERNATIVE
CHILDREN WITH TB/HIV INFECTION
ABC + 3TC + EFV
ABC or AZT + 3TC + EFV or NVP
ABC or AZT + 3TC + EFV
AZT + 3TC + ABC
WHAT ARE THE ARV DRUG PREPARATIONS FOR CHILDREN?
The range of commercially available paediatric ARV formulations is narrow and
most drugs do not have solid formulations in doses appropriate for paediatric use.
Lopinavir/ritonavir needs to be kept cool (<25 °C), and should be refrigerated prior
to dispensing. It can be kept out of the fridge for up to 42 days. If the caregiver has
a fridge at home, encourage them to store the lopinavir/ritonavir in the fridge. Do
not dispense more than one month’s supply if there is no fridge at home.
WHAT IS THE DOSING FOR ART?
Refer now to Annex 2. This explains the appropriate doses for antiretroviral
therapies.
ART DOSING IS LOCATED IN ANNEX 2
77
Ensure child has not breastfed for
at least 6 weeks
STEP 2: CAREGIVER ABLE TO GIVE ART
 YES  NO
 YES: caregiver available and willing to give medication
 YES: caregiver has disclosed to another adult, or is part of a support group
STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR
FIRST LEVEL FACILITY
• Weight under 3 kg
 YES  NO
• Child has TB
 YES  NO
•
•
If NO: classify as CONFIRMED HIV INFECTION NOT ON ART
If none present: GO TO STEP 3
IMCI DISTANCE
LEARNING
COURSE | MODULE 8. HIV/AIDS
YES  NO
• If any present: REFER NON-URGENTLY
•
If none present: GO TO STEP 4
STEP 4: ASSESS AND RECORD BASELINE INFORMATION
• Record weight and height,
 SEVERE ACUTE MALNUTRITION
assess & classify malnutrition
 MODERATE ACUTE MALNUTRITION
 NO ACUTE MALNUTRITION
• Pallor is present
 YES  NO
• Child has feeding problem
 YES  NO
• Hb: ............................. g/dl
Viral load: ....................................................
• CD4 count: ......................... cells/mm3 CD4 percentage ......................... %
• WHO clinical stage today: ................................................................................................
•
Send tests that are required
STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS
• Child is under 3 years old: Initiate preferred first-line regimen
• Child is 3 years or older: Initiate preferred first-line regimen
• Cotrimoxazole
• Give other routine treatments, including Vitamin A and immunizations
RECORD ARVS & DOSAGES HERE:
1. .............................................................................................................
2. .............................................................................................................
3. .............................................................................................................
REVIEW: WHAT PART OF THE
ART INITIATION FORM
• REFER IF:
—
COMPLICATED SEVERE ACUTE MALNUTRITION
IS USED FOR STEP 5?
— SEVERE OR SOME ANAEMIA
Review this section of the recording form to become familiar with the information.
•
If none present: GO TO STEP 5
RECORD OTHER TREATMENTS HERE:
PROVIDE FOLLOW-UP CARE
•
•
Follow-up after one week
If child is stable, follow-up regularly
78
NEXT FOLLOW-UP DATE: ..................................................
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
SELF-ASSESSMENT EXERCISE J – DOSING
Practice writing the drugs and the dosages for all first-line ARVs for the following
children. Refer to Annex 2 for dosing information.
Since accurate calculation of dosage based upon weight is the preferred method, use
the following example to practice calculating the dosage needed to treat children
of different weights. Refer to the ART drug dosage tables in your chart booklet, or
in the ANNEX of this module.
In this clinic the preferred regimen are the following:
•• Birth up to 3: ABC (20 mg/ml liquid) + 3TC (10 mg/ml liquid) + LPV/r
(80/20 mg liquid)
•• 3 years and older: ABC (20 mg or 300 mg tablet) + 3TC (30 mg tablet) +
EFV (200 mg tablet)
1. 12 month old 10 kg child
2. 4 year old 20 kg child
3. 4 month old 5 kg child
4. 13 month old 12 kg child
79
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
SELF-ASSESSMENT EXERCISE K – ART INITIATION
Bhengu works in a small clinic in a rural area. A doctor visits once a week. She sees
the following children. Decide whether each child requires: URGENT REFERRAL,
non-urgent referral to the doctor or whether Bhengu should initiate ART at the
clinic. Tick your answer.
URGENT
REFERRAL
NON-URGENT
REFERRAL FOR ART
ART AT
CLINIC
1. LEATILE: Leatile is four years old. He shows signs of severe acute malnutrition, and has CHRONIC EAR INFECTION,
but has no other problems. His CD4 count is 200 cells/mm3.



2. OFENTSE: Ofentse is three years old. She has been diagnosed with TB and on routine testing was found to be HIV-infected.



3. LUKE: Luke is two months old. When he was six weeks old he
was admitted to hospital with severe pneumonia. In the
hospital he was confirmed HIV infected. He is well now and is
gaining weight – his weight today is 4.5 kg. His CD4 count and
percentage have been sent, but the result is not back yet.



4. LENTSWE: Lentswe is four years old. He was seen a week ago
and you classified PNEUMONIA. Despite receiving an
antibiotic for five days he still has fast breathing (50 breaths
per minute). At the previous visit he was found to be HIVinfected, and his CD4 count is 150 mm3.



5. LEAH: Leah is 18 months old. Her CD4 count is not yet
available. Her Z-score is -3 but she has no other health
concerns.



6. OWETHU: Owethu is eleven months old. She was recently
confirmed HIV infection. Her mother wanted some time to
discuss starting Owethu on ART with her family, but had
agreed to come today to start treatment. Owethu’s mother says
that Owethu has been feverish since the previous day. When
you examine Owethu she finds that she is lethargic and does
not respond when her mother or Sister Bhengu speaks to her
or claps their hands.



80
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
PART 3: SIDE EFFECTS OF ARVs
WHAT ARE THE SIDE EFFECTS OF ARVS?
Most drugs have side effects of some sorts, although in the majority of cases they are
mild, and not all people taking drugs will experience the same effects and to the same
extent. Less than 5% of patients taking ART will have serious clinical side effects.
Many more will have non-serious, self-limiting side effects, especially at the
beginning of their therapy. If children and their caregivers know about possible
side effects it is easier to deal with them.
Caregivers and children must be aware of side effects, so that they do not
stop the drug in reaction to the side effect. This is important for adherence.
WHY IS IT IMPORTANT TO UNDERSTAND AND EXPLAIN
THESE SIDE EFFECTS?
Many mothers and children are worried about possible side effects when they start
ART for the first time. It is important that you warn mothers about the very common
side effects, and suggest ways in which the mother can manage these side effects.
If mothers or children do complain about side effects, you should take their
complaints seriously. Mothers of children with side effects may be concerned and
may stop giving the child the drug correctly because of this. Similarly children who
have side effects may refuse to take the medication. We have already discussed the
need to take all the doses to make sure the therapy works properly, and this should
be emphasized at each visit.
WHAT KINDS OF ARV SIDE EFFECTS ARE REPORTED?
ARV side effects can be divided into three categories.
1. Very common side effects
Warn patients and suggest ways patients can manage; also be prepared to manage when patients seek care.
2. Potentially serious side effects
Warn patients and tell them to seek care if they experience these side effects. These side effects are the ART
Danger Signs which you will learn about in the next section. If these signs are present, stop ART and REFER
URGENTLY.
3. Side effects occurring later during treatment
You will need to look out for these during follow-up visits. The table below describes commonly experienced
side effects of ARV drugs.
81
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
WHAT ARE IMPORTANT SIDE EFFECTS FOR ARVS?
Stavudine
(d4T)
VERY COMMON:
POTENTIALLY SERIOUS:
OCCURRING LATER DURING TREATMENT:
Inform patients and suggest
ways to manage; manage when
patients seek care
Warn patients
and tell them to
seek care
Discuss with patients
•• Nausea
•• Diarrhoea
Abacavir
(ABC)
•• Seek care urgently:
Severe abdominal
pain AND difficulty
breathing
•• Seek advice soon:
Tingling, numb or painful
feet or legs or hands.
•• Changes in fat distribution:
•• Arms, legs, buttocks, cheeks become
THIN
•• Breasts, tummy, back of neck become
FAT
•• Seek care urgently: fever,
vomiting, rash – this may
indicate hypersensitivity to
abacavir
Lamivudine •• Nausea
(3TC)
•• Diarrhoea
Lopinavir/
ritonavir
•• Nausea
•• Vomiting
•• Diarrhoea
Nevirapine
(NVP)
•• Nausea
•• Diarrhoea
Seek care urgently:
•• Yellow eyes
•• Severe skin rash
•• Fatigue AND shortness of
breath
•• Fever
Zidovudine
(ZDV or
AZT)
••
••
••
••
••
Nausea
Diarrhoea
Headache
Fatigue
Muscle pain
Seek care urgently:
•• Pallor (anaemia)
Efavirenz
(EFV)
••
••
••
••
••
••
••
Nausea
Diarrhoea
Strange dreams
Difficulty sleeping
Memory problems
Headache
Dizziness
Seek care urgently:
•• Yellow eyes
•• Psychosis or confusion
•• Severe skin rash
•• Elevated blood cholesterol and glucose
•• Changes in fat distribution:
—— Arms, legs, buttocks, cheeks become
THIN
—— Breasts, tummy, back of neck become
FAT
82
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
WHY IS IT IMPORTANT TO EXPLAIN SIDE EFFECTS FOR ALL DRUGS
IN A COMBINATION?
For all combination treatments, it is important to advise the mother about the
regimen as a whole and not on each specific drug.
The mother should never stop giving the child just one drug or giving him a
lower dose.
If the mother thinks that the child has a side effect from one drug, which is so bad
that she wants to stop or change the treatment, she should go with the child as
soon as possible to the clinic. Consult with the clinician or, if not available, STOP
ALL THREE DRUGS. Never just stop one or two drugs.
HOW DO YOU MANAGE SIDE EFFECTS?
Good management of side effects should include the following:
INTRODUCE: Discuss common possible side effects before the
child starts the medication
MANAGEMENT ADVICE: Give advice on how to manage these
side effects.
NOTIFY ABOUT SERIOUS SIDE EFFECTS: Warn mothers and
children about potentially serious side effects and tell them to
seek care urgently if they occur.
PROVIDE IMMEDIATE ATTENTION: Give immediate attention
to side effects, including access to the clinic or by phone
QUESTION DURING FOLLOW-UP: Initiate a discussion about
side effects, even if the mother or child does not mention them
spontaneously
REFER FOR SUPPORT: Refer the patient to peer-educators.
83
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
WHAT ARE APPROPRIATE CARE RESPONSES TO ART SIDE EFFECTS?
The table below outlines side effects experienced in patients on ART and appropriate
responses or advice for the caregiver. Only gastrointestinal upsets and fatigue are
fairly common in the small child treatment. Sleep disturbances, headaches and
memory problems are fairly common in Efavirenz containing regimens.
SIGNS or SYMPTOMS
RESPONSE
Yellow eyes (jaundice) or
abdominal pain
Stop drugs and REFER URGENTLY
Rash
If on abacavir, assess carefully. Is it a dry or wet lesion? Call for
advice. If the rash is severe, generalized, or peeling, involves
the mucosa or is associated with fever or vomiting: stop
drugs and REFER URGENTLY.
Nausea
Advise that the drug should be given with food. If persists for
more than 2 weeks or worsens, call for advice or refer.
Vomiting
Children may commonly vomit medication. Repeat the dose if
the medication is seen in the vomitus, or if vomiting occurred
30 minutes of the dose being given.
If vomiting persists, the caregiver should bring the child to
clinic for evaluation.
If vomiting everything, or vomiting associated with
severe abdominal pain or difficult breathing, REFER
URGENTLY.
Diarrhoea
Assess, classify, and treat using diarrhoea charts. Reassure
mother that if due to ARV, it will improve in a few weeks.
Follow-up as per chart booklet. If not improved after two
weeks, call for advice or refer.
Fever
Assess, classify, and treat using fever charts.
Headache
Give paracetamol. If on efavirenz, reassure that this is
common and usually self-limiting. If persists for more than 2
weeks or worsens, call for advice or refer.
Sleep disturbances,
nightmares, anxiety
This may be due to efavirenz. Give at night and take on an
empty stomach with low-fat foods. If persists for more than 2
weeks or worsens, call for advice or refer.
Tingling, numb or painful
feet or legs
Changes in fat distribution
If new or worse on treatment, call for advice or refer.
Consider switching from Stavudine to Abacavir. Refer if
needed.
84
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
SELF-ASSESSMENT EXERCISE L – SIDE EFFECTS
The table below lists common or potentially serious side effects to common ARV
drugs. For each side effect listed, fill in the name of the drug (or drugs – there
may be more than one) that cause the described side effect:
Side effect
* requires urgent care
Drug/s which causes the side effect
Severe abdominal pain
* potentially serious, because could be pancreatitis
Tingling or numbness in feet or hands
* this is neuropathy, should seek advice soon
Yellow eyes
* needs urgent referral as it may indicate liver toxicity
Skin rash
* It could be a severe reaction to the drug and may require
urgent referral.
Nausea, vomiting, diarrhoea Common -patients will need to
be prepared to cope with these side effects
Changes in fat distribution
Important side effect occurring with long term treatment
Fever, vomiting, skin rash
* may indicate hypersensitivity
Difficulty sleeping and nightmares
85
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
n How will you initiate ART for Peter?
Peter does not require any stabilization today for acute illness or opportunistic infections. As he is stable, you
will walk through the six steps for ART initiation today.
STEP 1: CONFIRM HIV INFECTION
Peter’s HIV infection has been confirmed through a positive virological test.
STEP 2: MAKE SURE LUNGILE IS READY TO GIVE ART
You will use the ‘5As’ to determine if Lungile is ready to give Peter ART:
1. ASSESS: Ask Lungile more about her social situation, as you have previously discussed. Ask her about
her understanding of HIV/AIDS. Ask what questions she has about HIV/AIDS and treatment. Ask her how
she feels about starting Peter on treatment now – can she handle this responsibility? Use small, specific
questions.
2. ADVISE: You will want to discuss key topics with Lungile. As she has already tested positive for HIV and is
receiving care, she might know this information already. Ask her questions about topics so that you can
try to understand what topics she might need more information about. These include: how HIV affects
the body, ART, and adherence. Ask Lungile checking questions to see if she understands.
3. AGREE: After you explain this information, ask Lungile how she feels about the treatment, and how Peter
will handle it. Ask her if she will be willing and able to come to appointments and give the medications
everyday at home.
4. ASSIST: Discuss what support Lungile has, and will need, for providing ART. This includes her ability
to bring Peter, for example transportation and time off work. It also includes stigma about giving
medications in the home, support from friends and family, and her choice to disclose to her partner,
mother, or friends.
5. ARRANGE: arrange another session with Lungile to continue discussing adherence.
STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR FACILITY
Peter does not require referral for ART. This is because he does not have TB or fast breathing, and he weighs
more than 3 kg. You will be able to initiate ART in your clinic.
86
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
ART: FOLLOW THE FIVE STEPS Name: .............................................................................
n STARTING
How will
you complete Peter’s recording form thus far?
ASSESS
Age: ......................
Weight: ............ kg
TREAT
 YES  NO
 Virological test positive
Ensure child has not breastfed for
at least 6 weeks
 Serological test positive
 Second serological test positive
Ensure child has not breastfed for
at least 6 weeks
•
•
Send any test required, including confirmation test
If HIV infection confirmed, and child is in stable
condition, GO TO STEP 2
STEP 2: CAREGIVER ABLE TO GIVE ART
 YES  NO
 YES: caregiver available and willing to give medication
 YES: caregiver has disclosed to another adult, or is part of a support group
•
•
If NO: classify as CONFIRMED HIV INFECTION NOT ON ART
If none present: GO TO STEP 3
•
•
If any present: REFER NON-URGENTLY
If none present: GO TO STEP 4
STEP 1: CONFIRM HIV INFECTION
• Child under 18 months:
•
Child 18 months and over:
Temperature: ..............
STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR
FIRST LEVEL FACILITY
• Weight under 3 kg
 YES  NO
• Child has TB
 YES  NO
 YES
 NO
RECORD ACTIONS AN
ALWAYS REMEMBER TO
PROVIDE ROUTINE CAR
STEP 4: ASSESS AND RECORD BASELINE INFORMATION
• Send tests that are required
• Record weight and height,
 SEVERE ACUTE MALNUTRITION
& classify malnutrition
 MODERATE ACUTE MALNUTRITION
• REFER IF:
STEPassess
4: ASSESS
AND RECORD
BASELINE INFORMATION
 NO ACUTE MALNUTRITION
— COMPLICATED SEVERE ACUTE MALNUTRITION
• Pallor
is present
 YES
OR SOME
ANAEMIA
Peter
is not
low weight for age and
he 
isNO
not anaemic. You review —
theSEVERE
clinical
staging.
You know that Peter
• Child has feeding problem
 YES  NO
has
had pneumonia, persistent diarrhoea,
and ear infections within the past couple of months. When you
• Hb: ............................. g/dl
Viral load: ....................................................
• If none present: GO TO STEP 5
assess
him today you see that herpes zoster is beginning to develop. You will send for the CD4 and viral load
• CD4 count: ......................... cells/mm3 CD4 percentage ......................... %
STARTING
ART:
FOLLOW
FIVE STEPS
Name:
Age: ...................... Weight: ............ kg
Temperature: ...............
tests
today,
and
will
fillTHE
in
results
once
they.............................................................................
return.
• WHO
clinical
stage
today:
................................................................................................
ASSESS
STEP
5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS
STEP
5: START
ARTold:
AND
COTRIMOXAZOLE
• Child
is under 3 years
Initiate
preferred first-line regimen
STEP 1: CONFIRM HIV INFECTION
 YES
• Child is 3 years or older: Initiate preferred first-line regimen
You
the first-line regimen
• will
Childdetermine
under 18 months:
 Virologicalfor
testPeter.
positive
 NO
•
•
Cotrimoxazole
Ensure
childAhas
breastfed for
Give other routine treatments, including
Vitamin
andnot
immunizations
at least 6 weeks
• Child 18 months and over:
 Serological test positive
Remember that Peter is 7.2 kg and
6.5 months
old.
 Second
serological
test positive
Ensure child has not breastfed for
PROVIDE FOLLOW-UP CARE
•• ABC (20 mg/ml): 4 ml AM, 4 ml
PM6 weeks
at least
n What ART doses will Peter require?
 YES  NO
 YES: caregiver available and willing to give medication
LPV/r:
YES: caregiver
disclosed
adult,
or PM
is part of a support group
(80/20hasmg):
1.5 to
mlanother
AM, 1.5
ml
2: CAREGIVER ABLE TO GIVE ART
•• STEP
3TC:
(10 mg/ml): 4 ml AM, 4 ml PM
••
STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR
FIRST LEVEL FACILITY
• Weight under 3 kg
 YES  NO
• Child has TB
 YES  NO
 YES
 NO
TREAT ARVS & DOSAGES HERE:
RECORD
1. .............................................................................................................
•2. Send
any test required, including confirmation test
.............................................................................................................
•3. If
HIV infection confirmed, and child is in stable
.............................................................................................................
condition, GO TO STEP 2
RECORD OTHER TREATMENTS HERE:
•
•
STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS
• Child is under 3 years old: Initiate preferred first-line regimen
• Child is 3 years or older: Initiate preferred first-line regimen
• Cotrimoxazole
• Give other routine treatments, including Vitamin A and immunizations
Follow-up after one week
If child is stable, follow-up regularly
•
•
If NO: classify as CONFIRMED HIV INFECTION NOT ON ART
If none present: GO TO STEP 3
•
•
If any present: REFER NON-URGENTLY
If none present: GO TO STEP 4
•
Send tests that are required
•
REFER IF:
— COMPLICATED SEVERE ACUTE MALNUTRITION
— SEVERE OR SOME ANAEMIA
•
If none present: GO TO STEP 5
n How will you finish Peter’s ART initiation form?
STEP 4: ASSESS AND RECORD BASELINE INFORMATION
• Record weight and height,
 SEVERE ACUTE MALNUTRITION
assess & classify malnutrition
 MODERATE ACUTE MALNUTRITION
 NO ACUTE MALNUTRITION
• Pallor is present
 YES  NO
• Child has feeding problem
 YES  NO
• Hb: ............................. g/dl
Viral load: ....................................................
• CD4 count: ......................... cells/mm3 CD4 percentage ......................... %
• WHO clinical stage today: ................................................................................................
RECORD ACTIONS AN
ALWAYS REMEMBER TO
PROVIDE ROUTINE CAR
NEXT FOLLOW-UP DAT
RECORD ARVS & DOSAGES HERE:
1. .............................................................................................................
2. .............................................................................................................
3. .............................................................................................................
RECORD OTHER TREATMENTS HERE:
•
•
PROVIDE FOLLOW-UP CARE
87
Follow-up after one week
If child is stable, follow-up regularly
NEXT FOLLOW-UP DAT
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
n How will you counsel Lungile on side effects?
Today you will inform Lungile about the possibility of side effects:
INTRODUCE: Discuss common possible side effects before the
child starts the medication
MANAGEMENT ADVICE: Give advice on how to manage these
side effects.
NOTIFY ABOUT SERIOUS SIDE EFFECTS: Warn mothers and
children about potentially serious side effects and tell them to
seek care urgently if they occur.
PROVIDE IMMEDIATE ATTENTION: Give immediate attention
to side effects, including access to the clinic or by phone
QUESTION DURING FOLLOW-UP: Initiate a discussion about
side effects, even if the mother or child does not mention them
spontaneously
REFER FOR SUPPORT: Refer the patient to peer-educators.
When Peter visits your clinic for follow-up, you will need to: (a) question Lungile to see if any side effects have
been occuring, (b) address any side effects, and (c) refer if necessary.
88
89
Child 18 months and over:
 YES  NO
 Virological test positive
Ensure child has not breastfed for
at least 6 weeks
 Serological test positive
 Second serological test positive
Ensure child has not breastfed for
at least 6 weeks
 YES
 NO
PROVIDE FOLLOW-UP CARE
STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS
• Child is under 3 years old: Initiate preferred first-line regimen
• Child is 3 years or older: Initiate preferred first-line regimen
• Cotrimoxazole
• Give other routine treatments, including Vitamin A and immunizations
STEP 4: ASSESS AND RECORD BASELINE INFORMATION
• Record weight and height,
 SEVERE ACUTE MALNUTRITION
assess & classify malnutrition
 MODERATE ACUTE MALNUTRITION
 NO ACUTE MALNUTRITION
• Pallor is present
 YES  NO
• Child has feeding problem
 YES  NO
• Hb: ............................. g/dl
Viral load: ....................................................
• CD4 count: ......................... cells/mm3 CD4 percentage ......................... %
• WHO clinical stage today: ................................................................................................
STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR
FIRST LEVEL FACILITY
• Weight under 3 kg
 YES  NO
• Child has TB
 YES  NO
STEP 2: CAREGIVER ABLE TO GIVE ART
 YES  NO
 YES: caregiver available and willing to give medication
 YES: caregiver has disclosed to another adult, or is part of a support group
•
STEP 1: CONFIRM HIV INFECTION
• Child under 18 months:
ASSESS
Weight: ............ kg
REFER IF:
— COMPLICATED SEVERE ACUTE MALNUTRITION
— SEVERE OR SOME ANAEMIA
If none present: GO TO STEP 5
•
•
•
•
Follow-up after one week
If child is stable, follow-up regularly
RECORD OTHER TREATMENTS HERE:
RECORD ARVS & DOSAGES HERE:
1. .............................................................................................................
2. .............................................................................................................
3. .............................................................................................................
Send tests that are required
If any present: REFER NON-URGENTLY
If none present: GO TO STEP 4
If NO: classify as CONFIRMED HIV INFECTION NOT ON ART
If none present: GO TO STEP 3
Send any test required, including confirmation test
If HIV infection confirmed, and child is in stable
condition, GO TO STEP 2
Age: ......................
•
•
•
•
•
•
•
TREAT
STARTING ART: FOLLOW THE FIVE STEPS Name: .............................................................................
Date: ....................
NEXT FOLLOW-UP DATE: ..................................................
RECORD ACTIONS AND TREATMENTS HERE:
ALWAYS REMEMBER TO COUNSEL THE MOTHER AND
PROVIDE ROUTINE CARE
Temperature: ............... °C
Akshay is a boy aged 30 months. He has been classified as HIV EXPOSED. He has severe oral thrush. His temperature is 36.7 °C and his weight now
is 10 kg. His height is 75 cm. For the past 3 months his weight has remained the same. He has not received any treatment for poor weight gain.
He has SOME ANAEMIA and his Hb is 8g/dL. A serological test was done which shows that he is HIV-infected. The diagnosis is confirmed with a
second test which is also positive. His blood was sent to the laboratory for a CD4 count. The absolute count was 250 cells/mm3, which was 12%.
Akshay’s mother has been on ART for the past year. She has been taking her medication every day and is very motivated to take care of herself
and of Akshay. She is supported by her mother who know that she is HIV-infected and on treatment. She now asks that Akshay should also receive
ART. Akshay lives with his mother. She runs a shop from home and looks after Akshay as well. Is Akshay is eligible for ART? If you decide that he is
eligible complete the ART initiation form.
CASE 1: AKSHAY
SELF-ASSESSMENT EXERCISE M – STEPS OF INITIATING ART
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
90
Child 18 months and over:
 YES  NO
 Virological test positive
Ensure child has not breastfed for
at least 6 weeks
 Serological test positive
 Second serological test positive
Ensure child has not breastfed for
at least 6 weeks
 YES
 NO
PROVIDE FOLLOW-UP CARE
STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS
• Child is under 3 years old: Initiate preferred first-line regimen
• Child is 3 years or older: Initiate preferred first-line regimen
• Cotrimoxazole
• Give other routine treatments, including Vitamin A and immunizations
STEP 4: ASSESS AND RECORD BASELINE INFORMATION
• Record weight and height,
 SEVERE ACUTE MALNUTRITION
assess & classify malnutrition
 MODERATE ACUTE MALNUTRITION
 NO ACUTE MALNUTRITION
• Pallor is present
 YES  NO
• Child has feeding problem
 YES  NO
• Hb: ............................. g/dl
Viral load: ....................................................
• CD4 count: ......................... cells/mm3 CD4 percentage ......................... %
• WHO clinical stage today: ................................................................................................
STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR
FIRST LEVEL FACILITY
• Weight under 3 kg
 YES  NO
• Child has TB
 YES  NO
STEP 2: CAREGIVER ABLE TO GIVE ART
 YES  NO
 YES: caregiver available and willing to give medication
 YES: caregiver has disclosed to another adult, or is part of a support group
•
STEP 1: CONFIRM HIV INFECTION
• Child under 18 months:
ASSESS
Weight: ............ kg
REFER IF:
— COMPLICATED SEVERE ACUTE MALNUTRITION
— SEVERE OR SOME ANAEMIA
If none present: GO TO STEP 5
•
•
•
•
Follow-up after one week
If child is stable, follow-up regularly
RECORD OTHER TREATMENTS HERE:
RECORD ARVS & DOSAGES HERE:
1. .............................................................................................................
2. .............................................................................................................
3. .............................................................................................................
Send tests that are required
If any present: REFER NON-URGENTLY
If none present: GO TO STEP 4
If NO: classify as CONFIRMED HIV INFECTION NOT ON ART
If none present: GO TO STEP 3
Send any test required, including confirmation test
If HIV infection confirmed, and child is in stable
condition, GO TO STEP 2
Age: ......................
•
•
•
•
•
•
•
TREAT
STARTING ART: FOLLOW THE FIVE STEPS Name: .............................................................................
Date: ....................
NEXT FOLLOW-UP DATE: ..................................................
RECORD ACTIONS AND TREATMENTS HERE:
ALWAYS REMEMBER TO COUNSEL THE MOTHER AND
PROVIDE ROUTINE CARE
Temperature: ............... °C
1. Is Nancy eligible for ART?
2. If you decide that she is eligible for ART complete the ART initiation form. You might need to know that Nancy is well, and there is no close
TB contact.
Nancy is 6 months old and weighs 3.3 kg. Her mother was found to be HIV-infected during pregnancy. Nancy was tested at six weeks and was
found to be PCR positive. Nancy’s CD4 count was 800 cells/ mm3 (30%). A full blood count done at the same time, showed that her Hb is 11g/dL.
She is breastfeeding and is generally well. Her length is 60 cm. Her temperature was recorded as 36.5 °C. She lifts her head when her mother
carries her with support, responds to sounds and follows close objects with both eyes. Her mother has not disclosed her own or Nancy’s HIV
status to anyone at home, but is a regular member of the clinic support group. She has been counselled regarding adherence, and is available
and committed to ensuring that Nancy receives her ARVs twice a day.
CASE 2: NANCY
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
8.9
PROVIDING FOLLOW-UP CARE
What are the learning objectives for this section?
After you study this section, you will know how to:
•• Provide follow-up care to children and young infants exposed to HIV
•• Explain the principles of good chronic care and how they can be used in your
clinic
•• Use the six steps for follow-up with children on ART
•• Know when to refer children on ART, both for urgent and non-urgent reasons
WHY IS FOLLOW-UP SO IMPORTANT FOR HIV EXPOSED INFANTS?
All children born to an HIV-infected mother are at risk of HIV infection. Effective
prevention of mother-to-child transmission (PMTCT) can reduce the risk of infection.
ARV prophylaxis is an important intervention to prevent HIV transmission from
mother to child. Please turn back to Section 8.6 to re-read this information.
It is also important that all children born to HIV-infected mothers are provided
follow-up care to ensure safe feeding, optimal growth and development, HIV testing,
and other care.
In high HIV settings, an important part of follow-up care for exposed infants
is an HIV test. Children classified as HIV EXPOSED will be reclassified once
you can confirm their HIV test results. You will provide care according to
their new classification.
WHAT ARE WAYS TO ENSURE THAT HIV-EXPOSED INFANTS
ARE TESTED?
All infants born to HIV-infected mothers should be offered PCR virological testing
at 4–6 weeks of age. This can be done when the child comes for immunizations. It
is very important that there is a system in every clinic for identifying infants and
offering testing. The infant should also initiate cotrimoxazole. The caregiver should
be counselled to return for HIV test results.
How can you work with your facility to better identify HIV-exposed infants?
Sometimes a clinic needs to be structured in a certain way to help identify more infants. For example,
integrated RCH clinics in health facilities and hospitals provide pregnant women and their children care
together. This helps a health worker respond to both the mothers’ and children’s needs. Another example is a
family-based care model. Here, all members of a family are linked for care. For example, if a mother or father
comes to the clinic, you ask about the health and HIV status of their children or partner, and keep their health
records together.
91
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
AFTER CHILD HAS CONFIRMED HIV INFECTION, WHAT FOLLOW-UP
IS PROVIDED?
When managing children with HIV, it is important to be able to provide both good
acute care and good chronic care at health facilities. There should be continuity
between services.
WHAT IS ACUTE CARE FOR CHILDREN INFECTED WITH HIV?
You learned about acute care in the IMCI case management course. Acute care
includes the management of common childhood illnesses, such as bacterial
infections, malaria, pneumonia, ear infections and skin conditions. In countries
with a high prevalence of HIV infection, more and more of these acute problems are
due to opportunistic infections that occur because of immunodeficiency caused
by HIV infection.
WHAT IS CHRONIC CARE FOR CHILDREN INFECTED WITH HIV?
HIV infection causes a chronic disease and this requires special health care. If
we only care for the patient during episodes of acute illness, then we are not yet
providing good chronic care. Good chronic care for children under the age of 5 years
recognises that the mother (or other primary caregiver) must understand and learn
to help with managing the child’s condition. The mother of an HIV-infected child
has a double burden: she must firstly cope with her own illness, and second learn
to manage and cope with her child’s illness.
HOW IS PROVIDING CHRONIC CARE DIFFERENT THAN ACUTE CARE?
Providing chronic care is different from providing acute care. When we provide
chronic care for an infant or child we have to take note of and follow several
principles. These principles are important and are listed below:
General Principles of Good Chronic Care for HIV-infected children
1. Develop a treatment partnership with the mother and child
2. Focus on the mother or child’s concerns and priorities
3. Use the IMCI counselling skills as well as the ‘5 As’ that you learned in this module
4. Support the mother and child’s self-management
5. Organize proactive follow-up
6. Involve “expert patients”, peer educators and support staff in your health facility
7. Link the mother and child to community-based resources and support
8. Use written information to document, monitor and remind.
9. Work as a clinical multidisciplinary team (i.e. nurses, social workers, counsellors, rehab therapists, doctors,
pharmacists and health promoters)
10.Assure continuity of care
92
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
Research has shown that when patients receive this kind of health care, they do
better. Five of these principles are explained in detail below:
1 HOW DO YOU DEVELOP A TREATMENT PARTNERSHIP?
What is a partnership? A partnership is an agreement between two or more people
to work together in an agreed way toward an agreed goal. For good chronic care, the
partnership is between the health worker (or clinical team) and the mother and child.
In a partnership both parties share responsibility for the agreement. Each
partner knows what role he or she plays in the partnership. Partners treat each
other with respect. One partner does not have all the power.
2 HOW DO YOU FOCUS ON THE MOTHER’S OR CHILD’S
CONCERNS AND PRIORITIES?
Often we focus only on the obvious signs or symptoms of illness and may miss the
real reason that the mother came to the clinic.
It is important to find out why the mother has come: Is the child sick? Does
he have a cough or diarrhoea or mouth sores or all three? Is the mother afraid or is
she having some difficulty or a psychosocial need? If the child is sick you will need
to Assess, Classify, Treat, Counsel and Follow-up this child for all the common
childhood illnesses. In addition, ask about or observe any psychosocial needs and
make sure that these are addressed.
3 HOW DO YOU USE COUNSELLING SKILLS YOU LEARNED IN
PREVIOUS MODULES?
The counselling skills that you learned in the INTRODUCTION (PART 2) and
previous modules will help you develop a good relationship with the mother and will
ensure that good long-term care is provided. For long-term care, the mother and the
child (depending on age and maturity) will need to agree to the treatment plan. The
health worker should assist the caretaker to overcome barriers to ensure long term
care. There need to be arrangements for definite follow-up dates and scheduling and
arranging for the mother to pick up medication such as cotrimoxazole prophylaxis
or ART.
4 HOW WILL YOU SUPPORT THE MOTHER AND CHILD SELFMANAGEMENT?
Whenever you think and speak about how an HIV-infected mother and her HIVinfected child should be managed, you need to realize that the mother should be left
as much in charge of her and her child’s care as is practically possible and feasible.
This self-help approach will give the mother a better sense of control and
make her feel better about her situation. It has been shown that this approach
makes people more successful in caring for themselves. Self-management recognizes
that the mother takes responsibility for the daily treatment of the child’s condition.
93
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
9 HOW WILL YOU WORK AS A CLINICAL TEAM?
Providing good chronic care (and also good acute care) requires teamwork. To be
able to deliver ART, this requires long-term commitment from a clinical
team that includes a nurse, clinical officer, an ART aid (for education, psychosocial
support and adherence counselling) and a medical officer or doctor. The team may
work together differently depending on where they are located.
SELF-ASSESSMENT EXERCISE N – FOLLOW-UP CARE
Complete this exercise about follow-up care for exposed and infected infants
or children
1. Children are classified during their first visit with you,
and you will continue to provide follow-up care according
to this classification
TRUE
FALSE
2. Children under 24 months are started on ART.
TRUE
FALSE
3. All children born to HIV-positive women should be
identified and provided HIV testing by PCR at 4–6 weeks
of age.
TRUE
FALSE
4. Sami is 8 months old, and had a negative PCR test while
he was still breastfeeding. He needs to be re-tested after
breastfeeding has been stopped for 4 weeks. TRUE
FALSE
5. Cotrimoxazole is an important element of follow-up care
for HIV-exposed and infected children.
TRUE
FALSE
6. Jyothi was classified as HIV EXPOSED. You will provide
follow-up and test for HIV as soon as possible.
TRUE
FALSE
94
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
WHAT ARE THE FOUR STEPS OF FOLLOW-UP CARE FOR CHILDREN
ON ART?
Follow the steps outlined below whenever you follow-up a child on ART. This followup lets you assess if ART drugs are working (child will be well and growing well with
few intercurrent infections), or causing any harm like side effects. You will read
details in the following pages.
STEP 1: ASSESS AND CLASSIFY
STEP 2: MONITOR PROGRESS ON ART AND
COTRIMOXAZOLE
➞ ASK: Does the child have any problems?
Has the child received care at another health
facility since the last visit?
➞ Assess and classify
for malnutrition and
anaemia
Record child’s height
and weight
➞ CHECK: for general danger signs
➞ ASSESS, CLASSIFY, TREAT: for main
symptoms using IMCI
➞ Assess adherence
Ask about adherence:
how often, if ever,
does the child miss
a dose? Record your
assessment.
➞ CHECK: for ART severe side effects
• Severe skin rash
• Difficulty breathing and
severe abdominal pain
• Yellow eyes
• Severe anaemia
• Fever, vomiting, rash
(only if on Abacavir)
If present,
REFER
URGENTLY
➞ Assess clinical stage
Assess clinical stage.
Compare with the
child’s stage at
previous visits.
IF ANY OF
FOLLOWING
PRESENT, REFER
NON-URGENTLY:
n Not gaining weight
for 3 months
n Poor adherence
n Stage worse than
before
n CD4 count lower
than before
n LDL higher than
3.5 mmol/L
n TG higher than
5.6 mmol/L
n Manage side
effects
n Send tests that are
due
➞ Monitor laboratory
results
Record results of tests that have been sent.
STEP 3: CONTINUE ART AND
OTHER MEDICATIONS
➞ If child is stable: continue with ART
and cotrimoxazole doses. Remember
these will need to increase as the
child grows
➞ If the child has developed
lipodystrophya on Stavudine,
substitute with Abacavir or
Zidovudine.
STEP 4: COUNSEL THE MOTHER OR CAREGIVER
Use every visit to educate and provide support to the mother
or caregiver
➞ Key issues to discuss include:
How the child is progressing, feeding, adherence, side
effects and correct management, disclosure (to others
and the child), support for the caregiver
➞ Remember to check that the mother and other
family members are receiving the care that they
need
➞ Set a follow-up visit: if well, follow-up in one month.
If problems, follow-up as indicated.
Lipodystrophy will be explained later in this section.
a
95
Name: .......................................................................................................... Age: ...................... Weight: ............ kg
Height: ............ cm
Temperature: ............... °C
Date: ....................
Height: ............................... cm
96
 CD4 COUNT: ............................... cells/mm3
 Other medications
 Efavirenz (EFV)
 Nevirapine (NVP)
 Abacavir (ABC)
3
 Lopinavir/Ritonavir (LPV/r)
 Nevirapine (NVP)
 Abacavir (ABC)
STEP 4: COUNSEL Use every visit to educate the caregiver and provide support. Key issues include:
 How is child progressing
 Adherence
 Support to caregiver
 Disclosure (to others & child)
 Side effects and correct management
 Mebendazole
 Lamivudine (3TC)
 Abacavir (ABC), or
 zidovudine (AZT)
OVER 3 YEARS:
OTHER MEDICATIONS:  Cotrimoxazole
2
 Lamivudine (3TC)
1
 Abacavir (ABC), or
 zidovudine (AZT)
If on LPV/r:  LDL Cholesterol: ...............................
STEP 3: CONTINUE
ART AND OTHER
MEDICATIONS
DATE: ...............................
Monitor blood results: Tests should be sent after 6 months on ARVs, then yearly. Record latest results here:
 COMPLICATED SEVERE ACUTE MALNUTRITION  UNCOMPLICATED SEVERE ACUTE MALNUTRITION
 MODERATE ACUTE MALNUTRITION
 NO MALNUTRITION
Assess development:
 Developing well
 Some delay
 Losing milestones
Assess adherence:
 Takes all doses
 Frequently misses doses
 Occasionally misses a dose
 Not taking medication
Assess clinical condition:
 Progressed to higher stage
Stage when ART initiated:  1  2  3  4  unknown
Weight: ............................... kg
 Other problems
 Diarrhoea
 Ear problem
Check for main symptoms:
 Cough or difficult breathing
 Fever
STEP 2: MONITOR PROGRESS ON ART AND COTRIMOXAZOLE
Assess and classify for malnutrition:
 Difficulty breathing and severe abdominal pain
 Fever, vomiting, rash (only if on Abacavir)
 CONVULSIONS DURING THIS ILLNESS
 LETHARGIC OR UNCONSCIOUS
Check for general danger signs:
 NOT ABLE TO DRINK OR BREASTFEED
 VOMITS EVERYTHING
Check for ART danger signs:
 Severe skin rash
 Yellow eyes
RECORD ACTIONS TAKEN:
RECORD ACTIONS TAKEN:
RECORD ISSUES DISCUSSED:
OTHER:
.......................................................................
DATE OF NEXT VISIT:
3. ......................................................................................................................................................................................
2. ......................................................................................................................................................................................
1. ......................................................................................................................................................................................
RECORD ART DOSAGE:
1. REFER NON-URGENTLY IF ANY OF THE
FOLLOWING ARE PRESENT:
✔ Not gaining weight for 3 months
✔ Loss of milestones
✔ Poor adherence despite adherence counselling
✔ Significant side effects despite appropriate
management
✔ Higher clinical stage than before
✔ CD4 count significantly lower than before
✔ LDL higher than 3.5 mmol/L
✔ TGs higher than 5.6 mmol/L
2. MANAGE MILD SIDE EFFECTS
3. SEND TESTS THAT ARE DUE
 CD4 count
 LDL cholesterol and Triglycerides
OTHERWISE, GO TO STEP 3
Assess, classify, treat, and follow-up according to IMCI
guidelines. Refer if necessary.
Provide pre-referral treatment and REFER
URGENTLY.
STEP 1: ASSESS AND CLASSIFY
ASK: does the child have any problems? If yes, record here: ...............................................................................................................................................................................................................................................................................................................
ASK: has the child received care at another health facility since the last visit?  YES  NO
ART FOLLOW UP
This follow-up form is in addition to the IMCI recording form. It provides critical instructions for the four steps of ART follow-up. The ART Follow-up
Recording Form provides an easy tool to remind you of the steps. Record the information on the form. All HIV-infected children should have a clinic
file where these forms, growth charts and laboratory results are filed.
RECORDING THE FOUR STEPS OF FOLLOW-UP CARE FOR CHILDREN ON ART
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
Step 1. ASSESS AND CLASSIFY
The first step when providing follow-up for a child on ART is to identify and manage
any serious problems or intercurrent illnesses.
HOW DO YOU IDENTIFY PROBLEMS FOR THE CHILD ON ART?
In order to identify problems so you can address them in follow-up care, you need to:
✔✔ Ask if the child has experienced any problems since the last visit
It is important to know how the child has been since the last visit, and whether
the mother has any concerns. Make sure that you address any concerns at some
point during the visit.
✔✔ Find out if the child has received care at another health facility since
the last visit
It is also important to know whether the child has received care at another
facility –intercurrent illnesses may suggest that ART is not working adequately,
or that the child is experiencing side effects. You will need to find out details
of any admissions to hospital including what treatment the child received, and
whether any changes were made to the child’s ARV medication.
✔✔ Check for general danger signs (IMCI charts)
✔✔ Check for ART Danger Signs
✔✔ Check for main symptoms (IMCI charts)
WHAT ARE ART SEVERE SIGNS?
As you learned about in the previous section, children on ART can develop side
effects. A very small number of children can develop serious life-threatening
side effects. Although these are very rare, they require immediate action, so it is
important to always ask about them.
ART SEVERE Signs are:
■■ Severe skin rash
■■ Difficulty breathing and severe abdominal pain
■■ Yellow eyes
■■ Two of the following:
•• Fever
•• Vomiting
•• Rash in a child on abacavir
If any of these danger signs are present, the child requires URGENT
REFERRAL. It is not necessary to complete the ART follow-up assessment, but
remember to provide relevant pre-referral treatment.
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Step 2. MONITOR ARV TREATMENT
Most children who are put on ART will start to thrive. Their weight will increase,
and they will experience fewer infections and other HIV-related problems. Many
children will not experience any side effects. Where side effects are present, these
are usually mild and will respond to simple measures.
Each follow-up visit provides the opportunity to assess whether the child is adhering
to ART and whether ART is working well. It is also important to find out whether
the child is experiencing any side effects. The steps can be outlined as follows:
1. Assess growth and nutritional status
2. Assess development
3. Assess adherence
4. Assess side effects
5. Assess stage
6. Monitor laboratory results
1. ASSESS THE CHILD’S GROWTH AND NUTRITIONAL STATUS
Children on ART should grow well and gain weight. It is important to monitor the
child’s height and weight on a regular basis. Follow the guidelines in the well child
module.
2. ASSESS DEVELOPMENT
It is important to assess the child’s development. Children on ART should develop
normally. Any child who is stalling in milestones should be referred. Review your
well child module.
3. ASSESS ADHERENCE
Adherence is key to successful ART. In order to be fully effective at least 95% of
doses should be taken. Decide which of the four adherence categories the
child fits into:
1. Takes all doses
2. Occasionally misses a dose (one or two doses missed per week)
3. Frequently misses doses (more than two doses missed per week)
4. Not taking medication
TIPS TO ASSESS: It is not always easy to assess, as caregivers may not want to tell
the health care worker that doses have been missed. Use a welcoming approach that
acknowledges that chronic medications can be difficult to take. Ask about the last
time the child missed a dose of ART and how often that occurs. This opens the
door to explore possible reasons for missed doses, such as multiple caregivers, travel
or simply forgetting. You may also be able to do a pill count to monitor adherence.
Once you categorize the child by one of the above 4 categories, document this on
your recording form. If poor adherence persists despite adherence counselling,
consider referral. Remember to praise and encourage good adherence at all visits.
Poor adherence = missing more than two doses per week
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4. ASSESS SIDE EFFECTS
Ask about any side effects, and manage as described in previous section. You
must refer if the child has any ART severe signs, or if side effects persist despite
appropriate management.
5. ASSESS CLINICAL STAGE
Assess the child’s stage at each visit. You can learn more about clinical staging
in Annex 1. Any new clinical stage 3 or 4 illness may be an indication that the ART
is no longer working well and the child must be referred.
6. MONITOR BLOOD RESULTS
Several clinical and laboratory assessments should be performed to help health
workers track a child’s progress on ART. These are in three stages:
■■ BASELINE: when children are identified as HIV-infected and enter into HIV
care, but are not yet eligible for ART
■■ ART INITIATION: when children initiate ART
■■ WHILE ON ART: ongoing to monitor response to ART
In resource-limited settings, the WHO recommends that clinical presentations
should also be used to monitor children on ART, in addition to laboratory results.
If laboratory monitoring is not available, for example CD4 counts or viral loads, it
should not prevent children from receiving ART. Other regular blood tests might
be included as per availability in the country. These may include viral load, and if a
child is on lopinavir/ritonavir, LDL cholesterol and triglyceride tests.
How will you monitor CD4 results?
CD4 counts and percentage should be monitored routinely. These tests should be
repeated after six months, after one year and thereafter annually. Normal CD4
counts are higher in young children than in adults and decrease with age to reach
adult levels around the age of 6 years. The absolute CD4 count depends on age and
so cannot be used in the same way as for adults to determine progression of HIV
infection.
What do the viral load (VL) test results mean?
✔✔ VL of less than 400 copies/mL: Suggests that ART is working well. The child
should receive routine follow-up and support, and the VL should be repeated
after a year.
✔✔ VL of between 400 and 1000 copies/mL: suggests that improvements are
required. Step-up adherence counselling, and repeat the test after six months.
✔✔ VL of above 1000 copies/mL: suggests that the ARVs are not working
adequately. This may be because of poor adherence, but may also be because
resistance is developing. Adherence counselling should be stepped-up, and the
VL should be checked after three months. If the VL is still above 1000 copies/
mL the child should be referred to the next level of care.
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HOW WILL YOU DETERMINE IF THERE IS TREATMENT FAILURE?
The detection of new or recurrent clinical events classified within the WHO clinical
staging (Annex 1) may also reflect progression of disease when a child is on ART.
Treatment failure should be considered when either new or recurrent clinical stage
3 or 4 events develop in a child adherent to therapy.
Using WHO paediatric clinical staging of events to guide decision-making on switching to second-line
therapy for treatment failure:
New or recurrent event develops
after at least 24 weeks on ARTa,b
Management optionsc,d
No new events or Stage 1 events
Do not switch to new regimen
Maintain regular follow-up
Stage 2 events
Treat and manage staging event
Do not switch to new regimen
Assess and offer adherence support
Assess nutritional status and offer support
Schedule earlier visit for clinical review and CD4 or viral load measurement where
available
Stage 3 events
Treat and manage staging event and monitor patient
Check if on treatment 24 weeks or more
Assess and offer adherence support
Assess nutritional status and offer support
Check CD4f or viral load where available
Institute early follow-up
Stage 4 events
Treat and manage staging event
Check if on treatment 24 weeks or more
Assess and offer adherence support
Assess nutritional status and offer support
Check CD4f or viral load where available
Consider switching regimen or refer to higher levels
A clinical event refers to a new or recurrent condition as classified in the WHO clinical staging at the time of evaluating the infant or child on
ART. Annexes C and D provides more details about clinical events.
b
It needs to be ensured that the child has had at least 24 weeks of treatment and that adherence to therapy has been assessed and
considered adequate before considering switching to a second-line regimen.
c
Differentiating OIs from IRIS is important.
d
In considering change of treatment because of growth failure, it should be ensured that the child has adequate nutrition and that any
intercurrent infections have been treated and resolved.
e
Pulmonary or lymph node TB, which are clinical stage 3 conditions, may not be an indication of treatment failure, and thus may not require
consideration of second-line therapy. The response to TB therapy should be used to evaluate the need for switching therapy.
f
CD4 measurement is best performed once the acute phase of the presenting illness has resolved.
a
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WHEN SHOULD A CHILD BE REFERRED?
However, some children will not thrive. This may be due to a number of reasons,
including:
•• Poor adherence – if the child is not taking the ARVs they cannot be expected
to have any effect. It may be helpful to enlist help from a treatment supporter.
If the problem persists, then refer the child to the doctor.
•• Untreated opportunistic infections e.g. TB.
•• Immune reconstitution – as the child’s immune function improves, symptoms
and signs can develop or worsen as the body begins to fight pre-existing
unrecognized or partially treated infections.
•• Inadequate nutrition
•• Resistance – the HI virus may have developed resistance to the ARVs that the
child is taking. The only option is to change the child to another (second-line)
regimen but this can only be done under expert supervision for which the child
should be referred – and only once adherence problems are excluded or attended
to.
WHEN SHOULD A CHILD BE REFERRED?
The following criteria can be used in deciding whether to refer a child.
•• Not gaining weight for 3 months
•• Loss of development milestones
•• Poor adherence despite adherence counselling
•• Significant side effects despite appropriate management
•• Higher clinical stage than before
•• CD4 count significantly lower than before
•• Viral load > 400 copies despite adherence counselling
Step 3. CONTINUE ART AND OTHER MEDICATIONS
If the child is stable, then ARVs should be prescribed and dispensed. Remember to
check that the child is receiving the correct dose at each visit.
IF THE CHILD IS STABLE, WHAT ACTIONS SHOULD BE TAKEN
ON ART?
Continue the child on the same regimen that they are currently on. This means that
most children will be on a first-line regimen. In general, children should only
receive first-line regimens at primary level. Decisions to change the regime
should only be taken by experienced clinicians who are usually based at treatment
centres or hospitals. Some children on second-line regimens may be referred back
to primary level for ongoing care. However, caring for children on these regimens
is not covered in IMCI.
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n Substituting Abacavir for Stavudine:
Nurses working at primary level should only prescribe first-line regimens, and should not substitute or
change any ARVs without consultation with an expert.
The one exception is as follows. Stavudine is being phased out as it has a number of side effects,
including peripheral neuropathy and lipodystrophy.
•• Peripheral neuropathy causes tingling sensations in the hands and feet.
•• Lipodystrophy is used to describe the development of an abnormal distribution of fat. It usually only
develops when the child has been on Stavudine for some time. The child’s arms, legs, buttocks and
cheeks become THIN, while the breasts, tummy, and back of neck become FAT. Lipodystrophy can be very
unsightly and may not resolve when treatment is stopped. It is therefore important to identify it early and
to switch to Abacavir in these children.
However children who were previously started on Stavudine, and are doing well on Stavudine should
remain on it.
Step 4. COUNSEL
Counselling is an ongoing process. Key issues that need to be discussed include:
✔✔ How the child is progressing
✔✔ Adherence
✔✔ Side effects and correct management
✔✔ Disclosure (to others and to the child)
✔✔ Support for the caregiver
✔✔ Access to local or government child and family support programmes
Counselling children for disclosure of their HIV status, to discuss antiretroviral
therapy (ART), and to support adherence to ART requires special effort and skills
in communication.
WHO IS RESPONSIBLE FOR DISCLOSING HIV STATUS TO A CHILD?
It remains the role of the caregiver to disclose HIV status to a child. Caregivers
should be counselled by a knowledgeable health care worker regarding disclosure.
Health care workers play an important role in helping to meet multiple client needs,
including gaining access to social support pre- and post-disclosure and improving
mental health.
Many health care workers express anxiety around disclosing HIV-status to
children. Several key principles and recommendations can help guide health care
workers. HIV disclosure should be viewed in a process-oriented approach.
Disclosure is not an “event”, instead it is an ongoing conversation with the child
that gradually involves more and more detail about his or her status and need for
medical treatments.
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WHY DISCLOSE TO A CHILD?
Increased knowledge and understanding about HIV helps to:
•• Facilitate children’s adjustment within the family and broader society
•• Boost self-esteem
•• Increase adherence to treatment
•• Decrease risky behaviours such as unprotected sex and multiple partners
•• Build stronger family ties to tackle more challenging issues in the future.
HOW DO YOU DISCLOSE HIV STATUS TO A CHILD?
Disclosure should be individualized to include the child’s level of understanding,
developmental stage, clinical status and social circumstances. As mentioned, it is
a process which can begin with partial disclosure where the child is presented with
information that avoids specific mention of HIV and AIDS. This is then followed
over time with full disclosure where detailed HIV and AIDS terminology is used.
The “Soldier Story” is one of many strategies commonly used to discuss concepts
about HIV, the body’s defences and the role of medication in a developmentally
appropriate way.
WHEN SHOULD HIV STATUS BE DISCLOSED TO A CHILD?
Several studies and developmental specialists advocate the need to consider each
child individually, and as such, a definite age for disclosure should not be outlined.
A general rule is that if a child is asking questions about their need to go to clinic,
take treatments or demonstrates oppositional behaviour related to treatment, this
is a sign they want more information and disclosure should be furthered.
Caregivers may oppose disclosure out of a natural response to “protect” the child
from negative information. This is an opportunity to explore further some of the
negative outcomes that have been observed should one fail timely disclosure:
✔✔ Impaired understanding of HIV increases ignorance of HIV
✔✔ Less participation in treatment
✔✔ Increased psychological and behavioural problems
✔✔ Decreased desire to access support services
✔✔ More complicated bereavement, difficulty dealing emotionally with illness,
dying and death
✔✔ Continuation of risky behaviours associated with adolescents
✔✔ Children can think about inaccurate and hurtful fantasies about their illness if
not properly informed
✔✔ Silence about their illness isolates the child
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✔✔ Increases the risk of accidental disclosure, where children find out by overhearing
conversations with other individuals. Self-discovery can undermine the child’s
sense of trust in adults
Adolescents, however, should know their HIV status. They should be fully
informed to appreciate consequences for many aspects of their health, including
sexual behaviour. They also require the information to make appropriate decisions
about their treatment plan.
SELF-ASSESSMENT EXERCISE O – FOLLOW-UP
The following children have come in for follow-up visits. They are all on ART.
Using the 4 steps, describe what you will do for each child.
1. Mandla is a 4 year old boy who has been on ART for 3 years. He is currently on
Stavudine, Lamivudine and Liponavir/ritonavir. His mother has noticed that
his face and arms are looking very thin, but that his body is looking fatter than
before.
2. Ross is a 9 month old boy has been on ART for two weeks. His mother complains
that he has not wanted to eat and has had diarrhoea. On examination he has
sunken eyes, but no other signs of dehydration.
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n What follow-up care will you provide to Peter?
You have classified Peter as HIV EXPOSED. He has been instructed to follow up monthly for care. When he
returns to the clinic, what follow-up care will you provide during visits?
✔✔ Provide routine child health care: Vitamin A, immunization, growth monitoring, and feeding assessment
and counselling
✔✔ Continue cotrimoxazole prophylaxis
✔✔ Assess, classify, and treat any new problems
✔✔ Ask about the mother’s health. Provide HIV counselling and testing and referral if necessary
n When will you retest Peter to confirm his HIV status?
Lungile decides to stop breastfeeding after Peter is 9 months old. She is out of the house working during the
days and is not able to breastfeed any more. Peter and Lungile return to the clinic 7 weeks after he stopped
breastfeeding. You will now re-test and classify Peter because he has not breastfed for at least 6 weeks.
n How will you retest Peter?
Peter is now almost 11 months old. He will require a virological test to confirm his status. First, it is important
than you provide counselling to Lungile about re-testing Peter and confirming his status. You also discuss
disclosure with her. Then, you draw specimen for a PCR test. Lungile needs to return for the results in 2
weeks. You schedule Peter for a follow-up visit to return for his test results.
n What happens when Peter and Lungile return for the results?
Lungile returns about two and a half weeks later for Peter’s PCR results. Peter’s results are positive. You
counsel Lungile on this news. She is very upset and says she feels very guilty that she made Peter sick. You
counsel her about this reaction, emphasizing that treatment will be very important for Peter and can keep
him healthy. You also discuss how Lungile will disclose Peter’s status.
n How will you re-classify Peter with these test results?
You first classified Peter as HIV EXPOSED because you didn’t have a test result. Now that a virological test is
positive, and Peter has not breastfed in over 6 weeks, you will reclassify as CONFIRMED HIV INFECTION.
n With Peter’s new classification, how will you provide follow-up care?
You have learned that all children under 5 years who are classified as CONFIRMED HIV INFECTION should
receive ART.
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n How will you provide follow-up care for Peter?
Peter has come for his first monthly follow-up visit. You will complete the following seven steps.
n STEP 1: ASSESS AND CLASSIFY
1. Conduct a full IMCI assessment: check for general danger signs and main symptoms
2. Ask Lungile if Peter has had any new problems since the last visit. Ask if he has received care from
anywhere else since the last visit.
3. Check for ART danger signs
4. Screen for TB
Lungile says there are no new problems. Peter does not have any general danger signs. You check for main
symptoms, and Peter has none. You check him for severe skin rash, difficult breathing, yellow eyes, fever, and
vomiting. He has none.
n STEP 2: MONITOR ART
Peter has gained a little weight to 7.4 kg. You talk to Lungile about adherence, and she says that she has given
all of the pills. She has brought the containers to show you. You praise her and encourage and she continue
such good adherence. You check for side effects and clinical staging, and there is no difference. You will
monitor the CD4 count and viral load tests that have come back. His CD4 count is 600 cells/mm3.
n STEP 3: PROVIDE ART
So far, Peter is stable. He will remain on this ART. You will continue to monitor him.
n STEP 4: COUNSEL PETER’S MOTHER
Counselling is an ongoing process. Key issues that need to be discussed include:
✔✔ How the child is progressing
✔✔ Adherence – especially in light of his detected viral load even though it is not very high.
✔✔ Side effects and correct management
✔✔ Disclosure (to others and to the child)
✔✔ Support for the caregiver, including local support services, government schemes, etc.
n FINALLY, ARRANGE NEXT VISIT
You are relieved to see Peter responding well to treatment. You praise his mother for good drug adherence.
You counsel when to come for the next visit.
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SELF-ASSESSMENT EXERCISE P – FOLLOW-UP
You will return to the cases of Akshay and Nancy. Read the cases below and
complete the ART follow-up recording forms on the following two pages.
CASE 1: NANCY
Nancy is now 12 months old. She has been doing very well. After six months of
treatment her CD4 count had risen to 1,200 cells/mm3, and her VL was 340 copies/
mm3. She has come for a routine follow-up visit. She was well until the previous
day, when she started vomiting. She has been able to drink fluids, but vomits after
every meal. Her mother noticed that her eyes are yellow. How will you provide
follow-up care today?
CASE 2: AKSHAY
Akshay has come for a follow-up visit. He has been on ART for three months and has
been doing well – he has been completely well in the last month and is developing
well. His weight is 12.5 kg, his height is 86 cm. He has no General Danger Signs,
ART Danger Signs or main symptoms. He is screened for TB, but does not require
further assessment for TB. His mother is proud that he never misses a dose of
ARVs. She tells the nurse that she has recently discovered that she is pregnant
again. Akshay has no symptoms or signs of HIV infection. He does not require any
routine treatments.
Complete the ART follow-up form.
107
Name: .......................................................................................................... Age: ...................... Weight: ............ kg
Height: ............ cm
Temperature: ............... °C
Date: ....................
Height: ............................... cm
108
 Other medications
 Efavirenz (EFV)
 Nevirapine (NVP)
 Abacavir (ABC)
3
 Lopinavir/Ritonavir (LPV/r)
 Nevirapine (NVP)
 Abacavir (ABC)
STEP 4: COUNSEL Use every visit to educate the caregiver and provide support. Key issues include:
 How is child progressing
 Adherence
 Support to caregiver
 Disclosure (to others & child)
 Side effects and correct management
 Mebendazole
 Lamivudine (3TC)
 Abacavir (ABC), or
 zidovudine (AZT)
OVER 3 YEARS:
OTHER MEDICATIONS:  Cotrimoxazole
2
 Lamivudine (3TC)
1
 Abacavir (ABC), or
 zidovudine (AZT)
If on LPV/r:  LDL Cholesterol: ...............................
 CD4 COUNT: ............................... cells/mm3
STEP 3: CONTINUE
ART AND OTHER
MEDICATIONS
DATE: ...............................
Monitor blood results: Tests should be sent after 6 months on ARVs, then yearly. Record latest results here:
 COMPLICATED SEVERE ACUTE MALNUTRITION  UNCOMPLICATED SEVERE ACUTE MALNUTRITION
 MODERATE ACUTE MALNUTRITION
 NO MALNUTRITION
Assess development:
 Developing well
 Some delay
 Losing milestones
Assess adherence:
 Takes all doses
 Frequently misses doses
 Occasionally misses a dose
 Not taking medication
Assess clinical condition:
 Progressed to higher stage
Stage when ART initiated:  1  2  3  4  unknown
Weight: ............................... kg
 Other problems
 Diarrhoea
 Ear problem
Check for main symptoms:
 Cough or difficult breathing
 Fever
STEP 2: MONITOR PROGRESS ON ART AND COTRIMOXAZOLE
Assess and classify for malnutrition:
 Difficulty breathing and severe abdominal pain
 Fever, vomiting, rash (only if on Abacavir)
 CONVULSIONS DURING THIS ILLNESS
 LETHARGIC OR UNCONSCIOUS
Check for general danger signs:
 NOT ABLE TO DRINK OR BREASTFEED
 VOMITS EVERYTHING
Check for ART danger signs:
 Severe skin rash
 Yellow eyes
RECORD ACTIONS TAKEN:
RECORD ACTIONS TAKEN:
RECORD ISSUES DISCUSSED:
OTHER:
.......................................................................
DATE OF NEXT VISIT:
3. ......................................................................................................................................................................................
2. ......................................................................................................................................................................................
1. ......................................................................................................................................................................................
RECORD ART DOSAGE:
1. REFER NON-URGENTLY IF ANY OF THE
FOLLOWING ARE PRESENT:
✔ Not gaining weight for 3 months
✔ Loss of milestones
✔ Poor adherence despite adherence counselling
✔ Significant side effects despite appropriate
management
✔ Higher clinical stage than before
✔ CD4 count significantly lower than before
✔ LDL higher than 3.5 mmol/L
✔ TGs higher than 5.6 mmol/L
2. MANAGE MILD SIDE EFFECTS
3. SEND TESTS THAT ARE DUE
 CD4 count
 LDL cholesterol and Triglycerides
OTHERWISE, GO TO STEP 3
Assess, classify, treat, and follow-up according to IMCI
guidelines. Refer if necessary.
Provide pre-referral treatment and REFER
URGENTLY.
STEP 1: ASSESS AND CLASSIFY
ASK: does the child have any problems? If yes, record here: ...............................................................................................................................................................................................................................................................................................................
ASK: has the child received care at another health facility since the last visit?  YES  NO
ART FOLLOW UP
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
SUMMARY: WHAT DID YOU LEARN IN THIS SECTION?
1. Follow-up for young infants exposed to HIV is critical for preventing
mother-to-child transmission.
Mothers should be told about the important need for follow-up during antenatal
care. Exposed infants should be offered PCR virological testing at 4-6 weeks of
age.
2. Regular follow-up care for exposed and infected children (who are not
receiving ART) includes:
•• Testing and counselling for HIV, both for the child and mother
•• Routine care like immunizations, feeding assessments and counselling,
Vitamin A
•• Cotrimoxazole prophylaxis, to reduce the risk of illness by bacterial infections
3. Infants and children need to be reclassified based on new test results.
Follow-up care should change according to the new classifications.
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
8.10 REVIEW QUESTIONS
AFTER THE MODULE: WHAT DO YOU KNOW NOW ABOUT
MANAGING HIV CARE FOR SICK CHILDREN AND INFANTS?
Now that you have finished the module, answer the same questions you tested before
you started studying. This will help demonstrate what you have learned!
1. A child is under 16 months old. What HIV test should be used for this child,
and why?
a. Serological tests, because it can detect if virus antibodies are present
b. Virological (PCR) tests, because it can actually detect the virus
c. Serological tests now, but after the child is 18 months, confirm with a PCR
2. What follow-up treatments are critical for HIV-exposed and infected infants
and children?
a. Cotrimoxazole prophylaxis
b.Paracetamol
c.Amoxicillin
3. What is the overall risk of a mother transmitting HIV to her child during
pregnancy, labour and delivery, and breastfeeding if no prophylaxis is used in
prevention of mother-to-child transmission?
a.70%
b.10%
c.35%
4. A 2 month breastfeeding baby has a positive virological (PCR) test. Is the child
HIV infected?
a. Yes, HIV-infected
b. No, HIV negative
c. Possibly, he is HIV exposed
5. When is an HIV-positive child or infant eligible for ART?
a. If a child has stage 2 HIV infection
b. Any child under five with confirmed HIV infection
c. Children over 5 years old with a count less than 350 cells per mm3
6. If a mother is HIV-positive, but the child is not confirmed with HIV infection,
what is the recommended feeding practice?
a. Exclusive breastfeeding as long as the child wants
b. Breastfeeding and also formula, in order to provide additional nutrition
c. Exclusive breastfeeding until 12 months
Check your answers on the next page. How did you do? ............... complete out of 5.
Did you miss questions?
Turn back to the section to re-read and practice the exercises.
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
8.11 ANSWER KEY
REVIEW QUESTIONS
Did you miss the question?
Return to this section to read and practice:
QUESTION
ANSWER
1
B
HIV TESTING
2
A
PROPHYLAXIS & OTHER PREVENTIVE MEASURES
3
C
BASIC INFORMATION ABOUT HIV
4
A
HIV TESTING
5
B
ANTIRETROVIRAL TREATMENT
6
C
COUNSEL HIV-POSITIVE MOTHERS ABOUT FEEDING
EXERCISE A – HIV TERMS
a. Immune system: The immune system protects the body against infections.
b.CD4: Lymphocytes are one of the types of white blood cell in the body and some of these
have a marker on their surface called CD4, and so are called CD4 lymphocytes. These
CD4 lymphocytes are responsible for warning your immune system that there are germs
trying to invade the body.
c. Opportunistic infection: An opportunistic infection is an infection which is not able to
attack a healthy body. When the body’s immune system is weak, the infection is able to
infect the body. Examples of opportunistic infections include thrush and herpes zoster.
EXERCISE B – HIV TESTING
11.An HIV virological (PCR) test detects the actual HIV virus or virus products in the
blood. An HIV serological test detects the presence of antibodies made in response
to the presence of HIV – however these antibodies can be from the mother and do
not disappear until the child is 18 months.
12.Virological (PCR)
13.Confirmed HIV infection
14.EXPOSED, not confirmed infection, as antibodies present can be from mother and
from breastfeeding. To confirm, child needs positive virological test at least 6 weeks
after stopping breastfeeding.
15.Confirmed HIV infection
16.Confirmed HIV negative
17. EXPOSED, breastfeeding should be done for 6 weeks and serological test completed
again
18.EXPOSED, because the child can still be infected through breastfeeding. Virological
(PCR) tests should be done 6 weeks after breastfeeding has stopped to confirm that
the child is HIV-negative.
19.YES, confirmed HIV negative
20.Yes, confirmed HIV negative
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
EXERCISE C – ASSESS & CLASSIFY SICK CHILD
a. TRUE: virological test is positive
b. FALSE: he should be classified HIV EXPOSED. Status must be confirmed after
breastfeeding has stopped for 6 weeks.
c. FALSE: she should be classified HIV EXPOSED. The status must be confirmed with
a virological test because the child is under 18 months old. The result can only be
confirmed 6 weeks after stopping breastfeeding.
d. TRUE: positive virological test in a child, and has not been breastfeeding for 4 months,
so is out of 6 week ‘window’.
e. TRUE: status must be confirmed after breastfeeding has stopped for 6 weeks.
f. FALSE: she should be classified as HIV EXPOSED. The result can only be confirmed
6 weeks after stopping breastfeeding.
g.TRUE
EXERCISE D – CLASSIFY YOUNG INFANT
1. HIV EXPOSED; test must be confirmed at least 6 weeks after breastfeeding stopped,
and with virological test
2. HIV INFECTION UNLIKELY
3. CONFIRMED HIV INFECTION
4. HIV INFECTION UNLIKELY
5. HIV EXPOSED; test must be confirmed at least 6 weeks after breastfeeding stopped,
and with virological test
EXERCISE E – COTRIMOXAZOLE
The following children should receive cotrimoxazole prophylaxis:
1. All young infants classified as CONFIRMED HIV INFECTION. Should start immediately.
• Children (under 12 months of age) classified as CONFIRMED HIV INFECTION
• Children (between 12 months and under 5 years of age) classified as CONFIRMED
HIV INFECTION when they are clinically staged at 2, 3, or 4. Their CD4% does not
matter. Should start immediately.
• Children (between 12 months and under 5 years of age) classified as CONFIRMED
HIV INFECTION who have a CD4% less than 25%. Their clinical stage does not
matter. Should start immediately.
• All children classified as HIV EXPOSED. Should start immediately.
• All young infants who are HIV EXPOSED. Should start from 4-6 weeks of age
2. All HIV-infected or -exposed infants should begin from 4-6 weeks of age. Otherwise,
children and young infants classified as HIV EXPOSED should start as soon as possible.
All HIV-infected children under 12 months should start immediately. All HIV-infected
children aged 12 months up to 5 years with WHO stage 2-3-4 or CD4% under 25%.
If children are HIV-infected and over 5 years of age, they follow adult guidelines for
cotrimoxazole.
3. Severe toxicity can include Steven Johnson syndrome or severe pallor
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
4. Answers are below:
a. YES; daily dose: 2.5ml syrup, or 1 paediatric tablet single strength
b. YES; daily dose: 5ml syrup, ½ adult tablet single strength, or 2 paediatric tablets
single strength
c.NO
d. YES; daily dose: 2.5ml syrup, or 1 paediatric tablet single strength
e.NO
f. YES; daily dose: 5ml syrup, ½ adult tablet single strength, or 2 paediatric tablets
g. YES; daily dose: 5ml syrup, ½ adult tablet single strength, or 2 paediatric tablets
h. YES; daily dose: 2.5ml syrup, or 1 paediatric tablet single strength; requires referral
today for SEVERE PNEUMONIA
i. YES; daily dose: 5ml syrup, ½ adult tablet single strength, or 2 paediatric tablets
j.NO
5. Cotrimoxazole prophylaxis should be stopped if: (a) children classified as EXPOSED
are confirmed HIV negative, and the child is not breastfeeding and has not for at
least 6 weeks, or (b) child develops severe drug reactions.
EXERCISE F – INTEGRATED TREATMENT
1. How would you treat a child with the classifications: HIV EXPOSED and PNEUMONIA?
•
•
•
•
•
•
Oral antibiotic for 5 days
Provide HIV test appropriate for age and breastfeeding status
If mother is HIV-positive, give nevirapine if indicated
Initiate cotrimoxazole
Provide Vitamin A and immunizations as required
Follow-up in 3 days for PNEUMONIA
2. When should you follow-up a child with the classifications: PERSISTENT DIARRHOEA
and HIV EXPOSED?
• Follow-up in 5 days on persistent diarrhoea, see if zinc and multivitamin treatment
is lessening diarrhoea and no other issues have developed
• Repeat HIV testing after breastfeeding has stopped for 6 weeks
3. How would you treat a child with the classifications: PNEUMONIA (wheeze present)
and HIV EXPOSED?
•
•
•
•
•
•
•
•
Oral antibiotic for 5 days
Give inhaled bronchodilator for 5 days
Advise on throat remedy
Provide HIV test appropriate for age and breastfeeding status
If mother is HIV-positive, give nevirapine if indicated
Initiate cotrimoxazole
Provide Vitamin A and immunizations as required
Follow-up in 3 days for PNEUMONIA
4. How would you treat a child with the classifications: PERSISTENT DIARRHOEA,
CONFIRMED HIV INFECTION, and exposure to TB?
• Zinc and multivitamins for 2 weeks
• Provide Vitamin A and immunizations as required
• Initiate cotrimoxazole prophylaxis
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
• Initiate ART if fulfills 5 steps for initiating in your clinic
• Initiate izoniazid preventive therapy (IPT) for 6 months
• Follow-up in 5 days for PERSISTENT DIARRHOEA
5. How would you treat a child with the classifications: PNEUMONIA, CHRONIC EAR
INFECTION, COMPLICATED SEVERE ACUTE MALNUTRITION, and CONFIRMED HIV
INFECTION?
•
•
•
•
Test for low blood sugar, then treat and prevent
Give first dose of antibiotic
Give ciprofloxacin
REFER URGENTLY (COMPLICATED SEVERE ACUTE MALNUTRITION is a severe
classification)
EXERCISE G – INFANT FEEDING
1.TRUE/FALSE
a. F – children need more feeds and fluids during illness
b.T
c. F – the child should be exclusively breastfed, especially as there is no risk of HIV
infection from the mother
d. T – the mother should breastfeed exclusively until 6 months of age, and then
begin adding safe complementary foods at 6 months in addition
e.T
f.T
g. F – according to studies, the risk of infection during breastfeeding is 15%
h. F – it is recommended for all women, regardless of HIV status, to breastfeed
exclusively at least for the first 6 months
i.T
2. Traci’s mother should begin adding family foods at 6 months of age. Foods should
include porridge and a mix of locally available foods, like eggs, mashed vegetables,
beans, and meat livers. If the child is not growing well, oil, margarine, or peanut
paste should be mixed with porridge. Traci should receive 2 meals a day from 6-8
months, and then increase to 5 meals a day.
EXERCISE H – CONFIRMING HIV INFECTION
1. Antiretrovirals are best used in combination to act against HIV and prevent rapid
drug resistance
2. Answers are below:
a.Yes
b.Yes
c. Possibly; Send a PCR test
d.Yes
e. Possibly; Repeat the child’s HIV test 6 weeks after breastfeeding stops. The test
will depend on the child’s age when the test is done.
f. Possibly; Send a confirmatory test as per national procedures
g.No
h. Possibly; Repeat the child’s HIV test after 5 weeks i.e. 6 weeks after breastfeeding
stopped. Use a serological test because the child is older than 18 months.
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
EXERCISE I – ART ELIGIBILITY
AGE
DETAILS
ANSWER
f. 4 years
Child is CONFIRMED HIV INFECTION
but appears healthy
YES
g. 6 months
Child is HIV exposed, and mother is
very sick
NO; need to confirm infection
h. 9 months
Child had a positive serological test
NO; need to confirm infection
i. 3 years
Child had a positive serological test
YES
j. 9 years
Child is CONFIRMED HIV INFECTION
HANDLED BY ADULT GUIDELINES
EXERCISE J – DOSING
1. 12 month old 10 kg child
a. ABC: 2 tablets (20 mg), twice a day
b. 3TC: 2 tablets (30 mg), twice a day
c. EFV: 1 tablet (200 mg) in evening
2. 4 year old 20 kg child
a. ABC: 3 tablets (60 mg), twice a day
b. 3TC: 3 tablets (30 mg), twice a day
c. EFV: 1.5 tablet (200 mg) in evening
3. 4 month old 5 kg child
a. ABC: 3ml, twice a day
b. 3TC: 1 tablet (30 mg), twice a day
c. LPV/r: 1ml, twice a day
4. 13 month old 12 kg child
a. ABC: 2 tablets (20 mg), twice a day
b. 3TC: 2 tablets (30 mg), twice a day
c. EFV: 1 tablet (200 mg) in evening
EXERCISE K – ART INITIATION
1. LEATILE: Start ART at clinic
2.OFENTSE: Non-urgent referral for ART because of her TB
3. LUKE: Start ART
4. LENTSWE: Urgent referral; his PNEUMONIA is not improving
5. LEAH: Non-urgent referral for ART because of SEVERE UNCOMPLICATED ACUTE
MALNUTRITION
6. OWETHU: URGENT REFERRAL
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
EXERCISE L – SIDE EFFECTS
Severe abdominal pain
*potentially serious, because could be pancreatitis
Stavudine
Tingling or numbness in feet or hands
* this is neuropathy, should seek advice soon
Stavudine
Yellow eyes
* needs urgent referral as it may indicate liver toxicity
Efavirenz
Skin rash
* It could be a severe reaction to the drug and may require urgent
referral.
Abacavir
Nausea, vomiting, diarrhoea Common -patients will need to be
prepared to cope with these side effects
Stavudine, Efavirenz
Lopinavir/ritonavir
Lamivudine
Changes in fat distribution
Important side effect occurring with long term treatment
Stavudine
Lopinavir/ritonavir
Fever, vomiting, skin rash
* may indicate hypersensitivity
Abacavir
Difficulty sleeping and nightmares
Efavirenz
EXERCISE M – BASELINE ASSESSMENT
CASE 1: AKSHAY
1. Akshay is eligible to receive ART. Criteria considered:
• He has confirmed HIV infection and is under 5 years of age.
• His mother has disclosed her HIV status to her mother and is willing to give ART
to Akshay.
2. Recording form follows.
CASE 2: NANCY
1. Nancy is eligible to receive ART. Criteria considered:
• She has confirmed HIV infection and is under 5 years of age.
• Her mother is willing to give her treatment. She has not disclosed to anyone at
home, but is a regular member of a support group.
2. Recording form follows.
116
Child 18 months and over:
✔YES  NO

 Virological test positive
Ensure child has not breastfed for
at least 6 weeks
✔Serological test positive

✔Second serological test positive

Ensure child has not breastfed for
at least 6 weeks
12
✔YES

 NO
117
250
3
PROVIDE FOLLOW-UP CARE
STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS
• Child is under 3 years old: Initiate preferred first-line regimen
• Child is 3 years or older: Initiate preferred first-line regimen
• Cotrimoxazole
• Give other routine treatments, including Vitamin A and immunizations
8
250 kg, 145 cm
STEP 4: ASSESS AND RECORD BASELINE INFORMATION
• Record weight and height,
 SEVERE ACUTE MALNUTRITION
assess & classify malnutrition
 MODERATE ACUTE MALNUTRITION
 NO ACUTE MALNUTRITION
• Pallor is present
 YES  NO
• Child has feeding problem
 YES  NO
• Hb: ............................. g/dl
Viral load: ....................................................
• CD4 count: ......................... cells/mm3 CD4 percentage ......................... %
• WHO clinical stage today: ................................................................................................
STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR
FIRST LEVEL FACILITY
✘ NO
• Weight under 3 kg
 YES 
✘ NO
• Child has TB
 YES 
9.1 kg
Weight: ............
•
•
Follow-up after one week
If child is stable, follow-up regularly
Treat thrush, ferrous gluconate 2.5ml tds
RECORD OTHER TREATMENTS HERE:
ABC (20 mg/ml) 6ml AM, 6ml PM
3TC (10mg/ml) 6ml AM, 6ml PM
EFV (200mg tablet) 1 in PM
RECORD ARVS & DOSAGES HERE:
1. .............................................................................................................
2. .............................................................................................................
3. .............................................................................................................
If none present: GO TO STEP 5
REFER IF:
— COMPLICATED SEVERE ACUTE MALNUTRITION
— SEVERE OR SOME ANAEMIA
•
•
Send tests that are required
If any present: REFER NON-URGENTLY
If none present: GO TO STEP 4
If NO: classify as CONFIRMED HIV INFECTION NOT ON ART
If none present: GO TO STEP 3
Send any test required, including confirmation test
If HIV infection confirmed, and child is in stable
condition, GO TO STEP 2
30 mo
Age: ......................
•
•
•
•
•
•
•
TREAT
Akshay
Name: .............................................................................
STEP 2: CAREGIVER ABLE TO GIVE ART
 YES  NO
✔ YES: caregiver available and willing to give medication

✔ YES: caregiver has disclosed to another adult, or is part of a support group

•
STEP 1: CONFIRM HIV INFECTION
• Child under 18 months:
ASSESS
STARTING ART: FOLLOW THE FIVE STEPS
Date: ....................
NEXT FOLLOW-UP DATE: ..................................................
− TST negative
− Viral load sent
− ARVs given
− Cotrimoxazole given
− Vitamin A 200 00IU
− Mebendazole 500 mg stat
− Mother counselled re: adherence
and side effects
− Follow-up in one week to check
progress
RECORD ACTIONS AND TREATMENTS HERE:
ALWAYS REMEMBER TO COUNSEL THE MOTHER AND
PROVIDE ROUTINE CARE
36.7 °C
Temperature: ...............
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
Child 18 months and over:
✔YES  NO

✔Virological test positive

Ensure child has not breastfed for
at least 6 weeks
 Serological test positive
 Second serological test positive
Ensure child has not breastfed for
at least 6 weeks
✔YES

 NO
118
800
31
550 copies/mm
30
PROVIDE FOLLOW-UP CARE
STEP 5: START ART TREAT AND COTRIMOXAZOLE PROPHYLAXIS
• Child is under 3 years old: Initiate preferred first-line regimen
• Child is 3 years or older: Initiate preferred first-line regimen
• Cotrimoxazole
• Give other routine treatments, including Vitamin A and immunizations
11
6 kg, 61 cm
STEP 4: ASSESS AND RECORD BASELINE INFORMATION
• Record weight and height,
 SEVERE ACUTE MALNUTRITION
assess & classify malnutrition
 MODERATE ACUTE MALNUTRITION
 NO ACUTE MALNUTRITION
• Pallor is present
 YES  NO
• Child has feeding problem
 YES  NO
• Hb: ............................. g/dl
Viral load: ....................................................
• CD4 count: ......................... cells/mm3 CD4 percentage ......................... %
• WHO clinical stage today: ................................................................................................
STEP 3: DECIDE IF ART CAN BE INITIATED AT YOUR
FIRST LEVEL FACILITY
✘ NO
• Weight under 3 kg
 YES 
✘ NO
• Child has TB
 YES 
3.3 kg
Weight: ............
•
•
Follow-up after one week
If child is stable, follow-up regularly
Cotrimoxazole 5ml daily
RECORD OTHER TREATMENTS HERE:
ABC (20mg/ml): 3ml AM, 3 ml PM
3TC: (10mg/ml): 3ml AM, 3 ml PM
LPV/r: (80/20mg): 1 ml AM, 1 ml PM
RECORD ARVS & DOSAGES HERE:
1. .............................................................................................................
2. .............................................................................................................
3. .............................................................................................................
If none present: GO TO STEP 5
REFER IF:
— COMPLICATED SEVERE ACUTE MALNUTRITION
— SEVERE OR SOME ANAEMIA
•
•
Send tests that are required
If any present: REFER NON-URGENTLY
If none present: GO TO STEP 4
If NO: classify as CONFIRMED HIV INFECTION NOT ON ART
If none present: GO TO STEP 3
Send any test required, including confirmation test
If HIV infection confirmed, and child is in stable
condition, GO TO STEP 2
6 mo
Age: ......................
•
•
•
•
•
•
•
TREAT
Nancy
Name: .............................................................................
STEP 2: CAREGIVER ABLE TO GIVE ART
 YES  NO
✔ YES: caregiver available and willing to give medication

✔ YES: caregiver has disclosed to another adult, or is part of a support group

•
STEP 1: CONFIRM HIV INFECTION
• Child under 18 months:
ASSESS
STARTING ART: FOLLOW THE FIVE STEPS
Date: ....................
NEXT FOLLOW-UP DATE: ..................................................
− ARVs given
− Cotrimoxazole given
− 10 week immunization given
− Mother counselled re: adherence
and side effects
− Follow-up in one week to check
progress
RECORD ACTIONS AND TREATMENTS HERE:
ALWAYS REMEMBER TO COUNSEL THE MOTHER AND
PROVIDE ROUTINE CARE
36.5 °C
Temperature: ...............
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
EXERCISE N – FOLLOW-UP CARE
1. False – children are reclassified according to test results, and follow-up care must
follow these new classifications
2. False – all children under 5 years should begin ART.
3.True
4. False – he should be re-tested after breastfeeding has been stopped for 6 weeks
5.True
6.True
EXERCISE O – ART AND DOSING
1.Mandla
a. Check his VL.
b. If VL is less than 400 copies/mL, stop Stavudine and replace it with Abacavir.
c. If VL is greater than 400 copies/mL, refer non-urgently.
1.Ross
a. Explain to his mother that the diarrhoea may be due to the ARVs, but that it is
likely to get better in a few weeks.
b. Stress the importance of adherence.
c. Advise mother to continue feeding and give SSS after each loose stool.
d. Follow-up in 5 days.
EXERCISE P – FOLLOW-UP
1. NANCY: Nancy’s ARVs must be stopped immediately. She must be referred urgently.
2. AKSHAY: see form below
FORM DATA:
•Akshay
• 33 months
• 86 cm
• 12.5 kg
• FOLLOW-UP VISIT
• STEP 1: NO problems, NO other visits. Nothing further to check.
• STEP 2: Check NO MALNUTRITION, DEVELOPING WELL, TAKES ALL DOSES
•BLOOD
• STEP 3:
1. ABC (20 mg/ml) 6 ml AM, 6 ml PM
2. 3TC (10 mg/ml) 6 ml AM, 6 ml PM
3. EFV (200 mg tablet) 1 in PM
• STEP 4: Discuss upcoming pregnancy, PMTCT, nutrition, family planning, ART
adherence…
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
ANNEXES
CONTENTS
Annex 1 Clinical staging
121
Annex 2 Treatment dosing tables
123
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IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
ANNEX 1 – CLINICAL STAGING
WHAT IS CLINICAL STAGING?
Once a child is confirmed to be HIV infected it is important to perform a task called
CLINICAL STAGING when you ASSESS the infant or child. If the child does not have
confirmed HIV infection but you suspect they have severe HIV disease, they will
need referral to assess whether ART is indicated. Please turn to the WHO Clinical
Staging chart on the next page to read more about severe HIV disease.
Clinical staging will help you estimate the degree of immune deficiency
the infant or child has. Staging uses a combination of signs and symptoms to
determine the degree of immune deficiency. When you STAGE an HIV-infected
infant or child you will need to LOOK, LISTEN, FEEL, and also conduct laboratory
tests if possible.
You should be aware of some of the staging criteria so that you can identify when a
child is in need of referral. According to the WHO REVISED PAEDIATRIC CLINICAL
STAGING developed in 2005, a child with confirmed HIV infection can fall into
one of four stages:
■■ STAGES 1 and 2 clinical statuses indicate that the immune system is not yet
seriously affected. Most conditions can be managed at first level facility.
■■ STAGES 3 and 4 indicate advanced immune deficiency. Most conditions need
URGENT REFERRAL.
HOW IS CLINICAL STAGING USED TO INDICATE ART?
Review the clinical stages on the following page. Carefully review the final row,
which discusses when ART is indicated for a child
■■ All children under 24 months of age with HIV INFECTION should be started
on ART irrespective of staging. However these children still need to be staged,
as changes in stage are used to monitor response to ART.
■■ In children 24 months and older, staging is used to decide whether or not
the child should receive ART. Once the child is on ART it is used to monitor the
child’s response.
SELF-ASSESSMENT EXERCISE – CLINICAL STAGING
Using the WHO paediatric clinical staging, where will you stage these HIV-infected
children?
STAGE
a. 4 years old with many lymph nodes more than 0.5 cm in diameter in the
axilla, groin and neck without underlying cause.
b. 6 months old and severe wasting which has not responded to treatment.
c. 9 months old with PERSISTENT DIARRHOEA (no response to treatment) and
herpes zoster.
d. 3 years old with persistent lymphadenopathy and recurrent SEVERE
PNEUMONIA
e. 9 years old with Kaposi’s sarcoma, otherwise well.
121
122
➞ Recurrent or chronic RTI
(sinusitis, ear infections,
otorrhoea)
➞ Mouth conditions
(recurrent mouth
ulcerations, angular
cheilitis, lineal gingival
Erythema)
b
➞ Cryptococcal meningitisa
➞ Toxoplasma brain abscessa
➞ Extrapulmonary tuberculosis
➞ Kaposi’s sarcoma
➞ Pneumocystis pneumonia (PCP)a
➞ Chronic HIV associated lung disease
including bronchiectasisa
➞ Acute necrotizing ulcerative gingivitis/
periodontitis
➞ Symptomatic LIPa
➞ Lymph node TB
b
for presumptive diagnosis of
severe HIV disease, see definition
below.
➞ HIV encephalopathya
➞ Recurrent severe bacterial pneumonia ➞ Acquired HIV-associated rectal
fistula
➞ Pulmonary TB
• Diarrhoea for over 14 days
• Fever for over 1 month
•Thrombocytopeniaa (under
50,000/mm3 for more than 1
month)
•Neutropeniaa (under 500/mm3
for 1 month)
• Anaemia for over 1 month
(haemoglobin under 8 gm)a
➞ Severe multiple or recurrent
bacterial infections ≥ 2 episodes
in a year (not including
pneumonia)
➞ More than one month of herpes
simplex ulcerations
➞ Oral hairy leukoplakia
➞ Unexplained and unresponsive to
standard therapy:
➞ Oesophageal thrush
Severe unexplained wasting/
stunting/Severe malnutrition not
responding to standard therapy
Stage 4
Severe Disease (AIDS)
➞ Oral thrush (outside neonatal period)
Moderate unexplained malnutrition not
responding to standard therapy
Stage 3
Moderate Disease
Conditions requiring diagnosis by a doctor or medical officer – should be referred for appropriate diagnosis and treatment.
In a child with presumptive diagnosis of severe HIV disease, where it is not possible to confirm HIV infection, ART may be initiated.
a
➞ Enlarged parotid
Persistent
generalized
lymphadenopathy
➞ Skin conditions (prurigo,
seborrhoeic dermatitis,
extensive molluscum
contagiosum or warts,
fungal nail infections,
herpes zoster)
➞ Enlarged liver and/or
spleen
No symptoms, or
only:
Symptoms
& signs
—
—
STAGE 2
Mild Disease
Growth
STAGE 1
Asymptomatic
This is only used for confirmed HIV infected children. Determine the clinical stage by assessing the child’s signs and symptoms. Look at the classification for each
stage. Decide what is the highest stage applicable to the child where one or more of the child’s symptoms are represented.
WHO PAEDIATRIC CLINICAL STAGING FOR HIV
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
ANNEX 2 – TREATMENT DOSING TABLES
WEIGHT
(Kg)
AZT/3TC
60/30 mg
tablet
AZT/3TC/NVP
300/150 mg
tablet
a.m.
p.m.
3–5.9
1
6–9.9
a.m.
60/30/50 mg
tablet
p.m.
ABC/AZT/3TC
300/150/200 mg
tablet
a.m.
p.m.
1
1
a.m.
p.m.
60/60/30 mg
tablet
ABC/3TC
300/300/150 mg
tablet
a.m.
p.m.
1
1
a.m.
60/30 mg
tablet
p.m.
600/300 mg
tablet
a.m.
p.m.
1
1
1
1.5
1.5
1.5
1.5
1.5
1.5
1.5
1.5
10–13.9
2
2
2
2
2
2
2
2
14–19.9
2.5
2.5
2.5
2.5
2.5
2.5
2.5
2.5
20–24.9
3
3
3
3
3
3
3
3
25–34.9
1
1
1
1
1
a.m.
p.m.
0.5
0.5
1
LOPINAVIR / RITONAVIR (LPV/R), NEVIRAPINE (NVP) & EFAVIRENZ (EFV)
LOPINAVIR / RITONAVIR (LPV/r)
WEIGHT
(KG)
EFAVIRENZ
(EFV)
NEVIRAPINE (NVP)
Target dose 15 mg/kg
once daily
Target dose 230–350 mg/m² twice daily
80/20 mg liquid
a.m.
p.m.
3–5.9
1 ml
6–9.9
1.5 ml
100/25 mg tablet
a.m.
p.m.
10 mg/ml liquid
50 mg tablet
200 mg tablet
a.m.
p.m.
a.m.
p.m.
1 ml
5 ml
5 ml
1
1
1.5 ml
8 ml
8 ml
1.5
1.5
10 ml
10 ml
a.m.
200 mg tablet
p.m.
a.m.
pm.
10–13.9
2 ml
2 ml
2
1
2
2
1
14–19.9
2.5 ml
2.5 ml
2
2
2.5
2.5
1.5
20–24.9
3 ml
3 ml
2
2
3
3
1.5
3
3
25–34.9
1
1
2
ABACAVIR (ABC), ZIDOVUDINE (AZT OR ZDV) & LAMIVUDINE (3TC)
WEIGHT
(KG)
ABACAVIR (ABC)
ZIDOVUDINE (AZT or ZDV)
Target dose: 8mg/kg/dose twice daily
Target dose 180–240mg/m² twice daily
20 mg/ml
liquid
60 mg
dispersible
tablet
300 mg
tablet
p.m.
60 mg
tablet
300 mg
tablet
150 mg
tablet
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
3–5.9
3 ml
1
1
6 ml
6 ml
1
1
3 ml
3 ml
1
1
6–9.9
4 ml
4 ml
1.5
1.5
9 ml
9 ml
1.5
1.5
4 ml
4 ml
1.5
1.5
10–13.9
6 ml
6 ml
2
2
2
2
6 ml
6 ml
2
2
14–19.9
2.5
2.5
2.5
2.5
2.5
2.5
20–24.9
3
3
3
3
3
3
1
1
1
123
p.m.
30 mg
tablet
3 ml
12 ml 12 ml
a.m.
10 mg/ml
liquid
a.m.
25–34.9
a.m.
10 mg/ml
liquid
LAMIVUDINE (3TC)
1
a.m.
p.m.
1
1
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
SIMPLIFIED HARMONIZED DOSING FOR CURRENTLY AVAILABLE TDF FORMULATIONS
FOR CHILDREN
Drug
TDFa
Size of powder
scoop (mg) or
strength of tablet
(mg)
Oral powder
scoops
40 mg/scoop
Tablets 150 mg
or 200 mg
Strength of
adult tablet
(mg)
Number of scoops or tablets by weight band once daily
3–5.9 kg
6–9.9 kg
10– 13.9 kg
14–19.9 kg
20–24.9 kg
–
–
3
–
–
Number of
tablets by
weight band
25–34.9 kg
1 (200 mg)b or
1 (300 mg)
300 mg
–
–
–
1 (150 mg)
1 (200 mg)
Target dose: 8 mg/kg or 200 mg/m2 (maximum 300 mg). The Paediatric Antiretroviral Working Group developed this guidance to harmonize TDF dosing with
WHO weight bands and to reduce the numbers of strengths to be made available. The WHO generic tool was used based on the target dose provided by the
manufacturer’s package insert. In accordance with the standard Paediatric Antiretroviral Working Group approach, dosing was developed ensuring that a child
would not receive more than 25% above the maximum target dose or more than 5% below the minimum target dose.
b
200-mg tablets should be used for weight 25–29.9 kg and 300-mg tablets for 30–34.9 kg.
a
SIMPLIFIED DOSING OF ISONIAZID (INH) AND COTRIMOXAZOLE (CTX,
SULFAMETHOXAZOLE (SMX) + TRIMETHOPRIM (TMP)) PROPHYLAXIS
Drug
Strength of tablet or
oral liquid
(mg or mg/5 ml)
Number of tablets or ml by weight band once daily
Strength
of adult
tab (mg)
10– 13.9 kg 14–19.9 kg 20–24.9 kg
Number
of tablets
by weight
band
3–5.9 kg
6–9.9 kg
25–34.9 kg
0.5
1
1.5
2
2.5
300 mg
1
INH
100 mg
CTX (SMX + TMP)
Suspension 200/40
per 5 ml
2.5 ml
5 ml
5 ml
10 ml
10 ml
–
–
Tablets (dispersible)
100 + 20 mg
1
2
2
4
4
–
–
Tablets (scored)
400 + 80 mg
–
one half
one half
1
1
400 +
80 mg
2
Tablets (scored)
800 + 160 mg
–
–
–
one half
one half
800 +
160 mg
1
Tablets (scored)
960 mg + 300 mg + 25 mg
–
–
–
one half
one half
960 mg +
300 mg +
25 mg
1
INH + CTX + B6a
This formulation is currently awaiting regulatory approval, and a scored junior tablet (480 mg + 150 mg + 12.5 mg ) is also under development.
a
124
IMCI DISTANCE LEARNING COURSE | MODULE 8. HIV/AIDS
PRACTICE USING THE DOSING TABLES!
List the ARVs with doses that the following children should receive based on drug
recommendations for their age and weight.
1. 3 year old boy. Weighs 14.5 kg.
2. 5 year old girl. Weighs 18.5 kg.
3. 2 month old boy. Weighs 6 kg.
4. 4 year old boy. Weighs 17 kg.
125
ISBN 978 92 4 150682 3